Meckel's diverticulum. Internal hernia and adhesions without gastrointestinal bleeding--ultrasound and scintigraphic findings.

The results from an ultrasound study performed on an 11-year-old boy, who had several weeks of intermittent abdominal pain, showed a nonperistaltic loop of bowel near the umbilicus, which suggested either an internal hernia or a diverticulum. Tc-99m pertechnetate imaging showed a focal collection near the umbilicus, which was consistent with a Meckel's diverticulum. No evidence was found of gastrointestinal bleeding. Exploratory laparotomy showed a Meckel's diverticulum near the terminal ileum and attached to the anterior abdominal wall close to the umbilicus. Small bowel had herniated through the loop formed by the terminal ileum and the diverticulum.

Gallbladder perforation. An imaging analysis.

We evaluated the radiologic studies of 23 patients with surgically or autopsy-documented gallbladder perforation. Extravasation was shown by cholescintigraphy and cholangiography in seven patients and corresponded to free perforation or large pericholecystic loculation. In 16 patients, ultrasonography and computed tomography detected fluid and abscesses outside the gallbladder ranging from 1 to 2 mm pericholecystic fluid collections to large phlegmonous masses. A right, upper-quadrant mass on plain films and scattered calcification in this area suggested perforation. Gallbladder perforation could be diagnosed or suspected preoperatively in ten patients and antemortem in 22 of 23 individuals. This rate of recognition, higher than previously reported, may be ascribed in part to improvements in biliary imaging.

Radioisotope bone scanning in a case of sarcoidosis.

The application of radioisotope scanning to osseous involvement from systemic sarcoidosis has been infrequently described in the scientific literature. Most commonly, the small bones of the hands and feet are affected if sarcoidosis involves the skeleton. Nonetheless, there are also occasional manifestations of sarcoid in the skull, long bones, and vertebral bodies. This paper describes a case of sarcoid involving the lung parenchyma with multiple lesions in the skull and ribs demonstrated by bone scanning with Tc-99m MDP. Following treatment with steroids, the bone scan showed complete resolution of the rib lesions and almost complete resolution of the lesions in the calvarium.

Diagnosis of spontaneous perforation of the gallbladder by Tc-99m DISIDA.

A case of spontaneous rupture of the gallbladder correctly diagnosed preoperatively using Tc-99m DISIDA cholescintigraphy is presented.

Abdominal manifestations of actinomycosis in IUD users.

The use of an intrauterine device (IUD) is associated with the presence of actinomyces in the female genital tract. Since IUD use is currently so prevalent, IUD-related pelvic inflammatory disease occasionally spreads to the rest of the abdomen. Two patients with abdominal actinomycosis in association with an IUD illustrate the problem; we review the general problem.

PIP: 2 case reports are presented of IUN wearers with advanced actinomycotic disease. In both women there was extensive involvement of the bowel and in 1 woman deposits in the liver. The discussion covers the objectives of making a preoperative diagonsis, initiating antibiotic therapy, and potentially obviating or limiting surgical intervention. A 44-year old black woman complained of gradually increasing abdominal girth, weight loss, weakness, and pedal edema. Her last menstrual period had been 5 months prior to admission. She had an IUD in place for 11 years and was sexually inactive. She was a cachectic woman with a temperature of 100 degrees Farenheit, bilateral inguinal adenopathy, and 1+ pedal edema. Barium studies revealed an IUD in the right side of the pelvis and a large soft tissue mass pressing upon and intimately adherent to the sigmoid colon. At laparotomy, mumerous adhesions were encountered and a large cavitated mass was found to occupy the entire left side of the pelvis. Fistulas extended from it to both the sigmoid colon and the small bowel. Frozen sections revealed fibrosis and inflammaion with confluent granulomas. Gram stains of the exudate showed sulfur granules suggesting atinomycotic infection. A total hysterectomy and bilateral salpingo-oophorectomy were performed and the intestinal fistuals were repaired. Examination of the resected specimens showed a Majzlin Spring IUD imbeded in the endometrium and myometrium. In the immediate postoperative period, the patient was treated with high dose intravenous antibiotic therapy and on discharge she was continued on oral penicillin. The 2nd case, a previously healthy 53 year old white woman gave a 2 month history of intermittent lower adbominal pain, cramping and alternating diarrhea and constipation. Her last menstrual period had been 6 months earlier and she claimed to have forgotten about a Dalkon Shield IUD which had been in place for 20 years. AT laparotomy, a firm infiltrating mass was found to involve the uterus, left fallopian tube, sigmoid colon, and pelvic side walls. Gross pathologic examination demonstrated extensive acute and chronic inflammation and granulation of the left fallopian tube, uterus, and sigmoid colon. The sigmoid showed thickening of musculas layers, reactive fibrosis in the submucosa, subserosa, and mesentery, and areas of formation of small sinus tracts and/or abscesses. A single sulfur granule was found within the lumen of the left fallopian tube. Gram stain of this demonstrated the characteristic filamentous nature of actinomyces. After surgery, Cefoxitan was continued and intravenous penicillin was added. Both patients were postmenopausal and had forgotten about their IUDs. Millions of women with IUDs are know to be asymptomatic carriers of actinomycosis by virtue of the appearance of the bacillus on routine Pap smears. Most of these women are still menstruating. Possibly cyclical menstrual flow is something of a cleansing mechanism protecting these women from actinomycotic infection.

The association of cleidocranial dysostosis with hearing loss.

Three new cases of cleidocranial dysostosis with hearing loss are reported in this paper. The significant points concerning this association are: (1) the hearing deficit is predominantly a middle ear conduction problem secondary to structural abnormalities of the ossicles; (2) there is sometimes a small bone conduction deficit indicating either a cochlear or an eighth nerve problem; (3) the middle ear hearing loss was corrected surgically in one reported case; (4) there is dense sclerosis of the temporal bone which makes a middle ear operation technically difficult; and (5) hearing loss with cleidocranial dysostosis may be more common than the number of cases in the literature suggests.