AIDS-related cholangiopancreatographic changes.

The cholangiographic and pancreatographic appearances of the acquired immunodeficiency syndrome (AIDS) associated cholangitis were evaluated in 26 patients. Twenty-four patients were diagnosed by retrograde cholangiography or endoscopic cholangiopancreatography (ERC or ERCP). One patient was diagnosed by T-tube cholangiography and another patient by transhepatic cholangiography. The radiographic findings ranged from intrahepatic ductal abnormalities with or without involvement of the extrahepatic biliary tree (eight patients) to irregularities and strictures involving the ampulla of Vater or the intrapancreatic portion of the common bile duct (CBD) with proximal dilatation (18 patients). Significant strictures involving the juxta-ampullary pancreatic duct were identified in six of 12 patients. Twenty-one of the 26 patients had associated infections which included: Cryptosporidium (CS), Mycobacterium avium intracellulare (MAI), cytomegalovirus (CMV), Microsporidium (MSP), and Isospora (ISP). Three patients were operated upon for acute acalculous cholecystitis. In each instance, organisms were identified in both the bile duct and the inflamed gallbladder.

Endoscopic management of biliary tract stones and stenosis.

The role of endoscopy in managing biliary tract stones and stenosis is surveyed. Rapid advances in endoscopic videoimaging with small diameter maneuverable or large instrument channel endoscopes allows diagnosis and therapy under visual or radiographic control at almost any site in the biliary tree. Techniques for cytology, biopsy, sphincterotomy, mechanical or laser lithotripsy, dilatation with balloon or bougie, large (15 F) or small stent insertion, "polypectomy" or excision with laser or electrosurgery, and brachytherapy provide a therapeutic armamentarium that must be considered as painless, low risk, and cost-effective alternatives to surgical or percutaneous therapy.

Cryptosporidiosis of the stomach and small intestine in patients with AIDS.

Cryptosporidiosis is a parasitic disease of the gastrointestinal tract that causes a choleralike diarrhea in patients with the acquired immunodeficiency syndrome (AIDS). Review of barium studies of the stomach and small intestine in 16 AIDS patients with cryptosporidiosis showed that the studies were abnormal in 13. Of these, five had moderate or marked prominence of the mucosal folds, and eight had slight prominence. The jejunum was predominantly involved in nine; the entire small intestine was uniformly affected in the other four. Three of the 16 patients had moderate or marked dilatation of the small intestine. One had marked dilution of the barium, and one had marked fragmentation and flocculation of the barium. There was narrowing and rigidity of the gastric antrum in two patients. These radiographic findings are nonspecific, but are indicative of cryptosporidiosis in a patient with AIDS and protracted diarrhea.

Percutaneous pancreatography: case report and presentation of technique.

A case of traumatic pancreatitis with a radiopaque calculus producing pain by obstructing the distal pancreatic duct is presented. Preoperative ductal anatomy was defined by a percutaneous pancreatogram that established the presence of mechanical duct obstruction as the cause of pain, and the potential for operative relief of duct obstruction. A remission from pain resulted from pancreatic duct decompression by a lateral pancreaticojejunostomy. The potential value of percutaneous pancreatography is discussed.

Advances in the management of bile duct obstruction: percutaneous transhepatic cholangiography and endoscopic retrograde cholangiopancreatography.

Jaundice can be diagnosed anatomically and frequently histopathologically without laparotomy by radiologic and endoscopic techniques, combined with biopsy or cytology. Benign and malignant causes of bile duct obstruction can be managed by endoscopic and radiologic methods with reduced morbidity and mortality, displacing abdominal operation for many entities. Even unresectable or inoperable lesions can be effectively palliated by these new techniques.

Radiology of papilla of Vater stenosis.

The radiographic characteristics of the terminal pancreatic and biliary ducts were analyzed by endoscopic retrograde cholangiopancreatography in 25 patients with documented benign stenosis of the papilla of Vater. Demonstration of marked hypertrophy of the distal sphincter, mucosal hyperplasia or mucosal redundancy of the distal common bile duct, dilatation of the ducts, and prolonged retention of contrast media suggest papillary stenosis. The diagnosis of benign papillary stenosis, however, ultimately depends on physiologic measurements and response to therapy.

Choledochocele: radiologic diagnosis and endoscopic management.

A case of choledochocele, missed during exploratory laparotomy but managed by endoscopic biliary surgery, is presented.

The radiology corner. Neonatal small left colon syndrome.

The signs and symptoms of intestinal obstruction in the newborn infant often present a difficult diagnostic problem. Plain films often fail to differentiate small from large bowel obstruction. Contrast studies may be decisive and indicate the site of obstruction and its etiology. This is especially important in nonsurgical conditions as the following case of the "neonatal small left colon syndrome" illustrates.

The radiology corner. Bouveret's syndrome.

A case of gallstone obturation of the duodenal bulb is presented. The general topic of gallstone ileus is briefly discussed and a review of the reported cases of Bouveret's syndrome is presented. The radiographic criteria for diagnosis of these entities are emphasized.

Colonic polyp detection: role of roentgenography and colonoscopy.

In order to determine the relative yields of colonoscopic and radiologic examinations of the colon, the following guidelines are suggested: (a) prospective data collection; (b) a standard, effective colon cleansing regimen; (c) colonoscopic and radiologic examiners of comparable expertise; (d) examiners should be unaware of each other's findings; (e) a suitable method for demonstrating false-negative findings and for resolving conflicting findings between the two examinations; and (f) indexing of the study findings as to lesion size, lesion location, quality of colon cleansing, and examiner's level of confidence. The two examinations should be used as complementary diagnostic procedures.

Indications, clinical value and complications of endoscopic retrograde cholangiopancreatography.

Endoscopy combined with endoscopic retrograde cholangiopancreatography is a unique tool providing a broad, precise yield of diagnostic information about diseases of the upper gastrointestinal tract. In the absence of gross anatomic disease, its diagnostic accuracy should exceed 90 per cent and risk be minuscule. The incidence of complications and, therefore, risk to the patient and proportional to the magnitude and remedial nature of the disease processes found. In the absence of diagnostic procedures for diseases of the biliary tree and pancreas that are riskless, the relationship of endoscopic retrograde cholangiopancreatography risk to diagnostic value and patient salvage emphasizes the value of endoscopy combined with endoscopic retrograde cholangiopancreatography as the diagnostic procedure of choice for patients with suspected disease of the biliary tract or pancreas. The unique value of endoscopic retrograde cholangiopancreatography in providing rapid visualization of diseases of the upper gastrointestinal tract mucosa combined with cholangiography and pancreatography is dramatized in the patient with upper abdominal pain syndrome with or without jaundice. In the face of a rapidly evolving illness and the potential need for early surgical intervention, barium studies are relatively contraindicated and have a poor diagnostic yield. By contrast, endoscopic retrograde cholangiopancreatography combined with endoscopy rapidly rules out, or, in the presence of disease of the upper gastrointestinal tract, permits the immediate use of subsequent diagnostic procedures. An experience with more than 1,000 procedures reveals that endoscopic retrograde cholangiopancreatography is an invaluable tool for the diagnosis and management of disease of the pancreas and biliary tract.

The radiologic diagnosis of spontaneous mesenteric venous thrombosis.

Spontaneous mesenteric venous thrombosis is a distinct clinicopathologic entity that typically presents as abdominal pain of obscure origin. Pathologically, thrombosis of multiple small tributaries of the superior mesenteric vein causes segmental congestion, edema, hemorrhage and ultimately mucosal necrosis. Characteristic radiologic changes were found in 10 of 12 cases.

Torsion of the wandering spleen.

We report 2 cases of torsion of the wandering spleen that illustrate the roentgenologic features of this unusual condition. These are an abdominal mass, usually in the left flank of pelvis; absence of the splenic shadow beneath the left diaphragm; extrinsic compression of the colon at the level of the phrenicocoloc ligaments by the elongated splenic pedicle; and evidence of splenic vein occlusion, as indicated by gastric varices in the absence of esophageal varices. A combination of these findings should permit diagnosis or lead to angiographic or isotopic studies to confirm the presence of a wandering spleen.