RESUMO
BACKGROUND: Level 1 programs have improved outcomes by expediting the multidisciplinary care of critically ill patients. We established a novel level 1 program for the management of esophageal emergencies. METHODS: After institutional review board approval, we performed a retrospective analysis of patients referred to our level 1 esophageal emergency program from April 2013 through November 2015. A historical comparison group of patients treated for the same diagnosis in the previous 2 years was used. RESULTS: Eighty patients were referred and transported an average distance of 56 miles (range, 1-163 miles). Median time from referral to arrival was 2.4 hours (range, 0.4-12.9 hours). Referrals included 6 (7%) patients with esophageal obstruction and 71 (89%) patients with suspected esophageal perforation. Of the patients with suspected esophageal perforation, causes included iatrogenic (n = 26), Boerhaave's syndrome (n = 32), and other (n = 13). Forty-six percent (n = 33) of patients were referred because of pneumomediastinum, but perforation could not be subsequently demonstrated. Initial management of patients with documented esophageal perforation included operative treatment (n = 25), endoscopic intervention (n = 8), and supportive care (n = 5). Retrospective analysis demonstrated a statistically significant difference in mean Pittsburgh severity index score (PSS) between esophageal perforation treatment groups (p < 0.01). In patients with confirmed perforations, there were 3 (8%) mortalities within 30 days. More patients in the esophageal level 1 program were transferred to our institution in less than 24 hours after diagnosis than in the historical comparison group (p < 0.01). CONCLUSIONS: Development of an esophageal emergency referral program has facilitated multidisciplinary care at a high-volume institution, and early outcomes appear favorable.
Assuntos
Gerenciamento Clínico , Emergências , Serviços Médicos de Emergência/métodos , Perfuração Esofágica/terapia , Estenose Esofágica/terapia , Esofagoscopia/métodos , Desenvolvimento de Programas/métodos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Perfuração Esofágica/diagnóstico , Estenose Esofágica/diagnóstico , Feminino , Humanos , Indiana , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Tempo , Adulto JovemRESUMO
It is difficult to identify normal peritoneal folds and ligaments at imaging. However, infectious, inflammatory, neoplastic, and traumatic processes frequently involve the peritoneal cavity and its reflections; thus, it is important to identify the affected peritoneal ligaments and spaces. Knowledge of these structures is important for accurate reporting and helps elucidate the sites of involvement to the surgeon. The potential peritoneal spaces; the peritoneal reflections that form the peritoneal ligaments, mesenteries, and omenta; and the natural flow of peritoneal fluid determine the route of spread of intraperitoneal fluid and disease processes within the abdominal cavity. The peritoneal ligaments, mesenteries, and omenta also serve as boundaries for disease processes and as conduits for the spread of disease.
Assuntos
Diagnóstico por Imagem/métodos , Peritônio/anatomia & histologia , Espaço Retroperitoneal/anatomia & histologia , Cavidade Abdominal/diagnóstico por imagem , Cavidade Abdominal/embriologia , Adulto , Idoso , Ascite/diagnóstico por imagem , Ascite/patologia , Feminino , Humanos , Ligamentos/diagnóstico por imagem , Imageamento por Ressonância Magnética/métodos , Masculino , Mesentério/anatomia & histologia , Mesentério/diagnóstico por imagem , Mesentério/embriologia , Pessoa de Meia-Idade , Tomografia Computadorizada Multidetectores , Cavidade Peritoneal/diagnóstico por imagem , Peritônio/diagnóstico por imagem , Peritônio/patologia , Peritonite/diagnóstico por imagem , Espaço Retroperitoneal/diagnóstico por imagem , Espaço Retroperitoneal/patologia , Tomografia Computadorizada por Raios X/métodos , Ultrassonografia , Vísceras/diagnóstico por imagem , Vísceras/patologiaRESUMO
The clinical treatment of patients with anorectal and pelvic floor dysfunction is often difficult. Dynamic cystocolpoproctography (DCP) has evolved from a method of evaluating the anorectum for functional disorders to its current status as a functional method of evaluating the global pelvic floor for defecatory disorders and pelvic organ prolapse. It has both high observer accuracy and a high yield of positive diagnoses. Clinicians find it a useful diagnostic tool that can alter management decisions from surgical to medical and vice versa in many cases. Functional radiography provides the maximum stress to the pelvic floor, resulting in levator ani relaxation accompanied by rectal emptying-which is needed to diagnose defecatory disorders. It also provides organ-specific quantificative information about female pelvic organ prolapse-information that usually can only be inferred by means of physical examination. The application of functional radiography to the assessment of defecatory disorders and pelvic organ prolapse has highlighted the limitations of physical examination. It has become clear that pelvic floor disorders rarely occur in isolation and that global pelvic floor assessment is necessary. Despite the advances in other imaging methods, DCP has remained a practical, cost-effective procedure for the evaluation of anorectal and pelvic floor dysfunction. In this article, the authors describe the technique they use when performing DCP, define the radiographic criteria used for diagnosis, and discuss the limitations and clinical utility of DCP.
Assuntos
Canal Anal/diagnóstico por imagem , Canal Anal/fisiopatologia , Defecografia/métodos , Diafragma da Pelve/diagnóstico por imagem , Diafragma da Pelve/fisiopatologia , Colposcopia/métodos , Meios de Contraste , Cistocele/diagnóstico por imagem , Cistocele/fisiopatologia , Cistoscopia/métodos , Feminino , Humanos , Masculino , Prolapso de Órgão Pélvico/diagnóstico por imagem , Prolapso de Órgão Pélvico/fisiopatologia , Exame Físico , Retocele/diagnóstico por imagem , Retocele/fisiopatologiaRESUMO
In the 1980s and 1990s in North America and Europe, air (CO(2)) double-contrast barium enteroclysis took a back seat to biphasic methylcellulose double-contrast enteroclysis in the investigation of small-bowel diseases. The widespread application of capsule endoscopy in the 21st century has identified a number of limitations of radiologic examinations in the investigation of mucosal diseases of the small intestine. Evidence-based studies comparing barium, computed tomographic (CT), and magnetic resonance (MR) enteroclysis have shown that in spite of improvements in small-bowel examination methods using CT and MR, barium examinations remain superior in the depiction of mucosal abnormalities, particularly the apthoid lesions of early Crohn disease. Barium small-bowel examinations have been recommended in the patient with a negative CT or MR enteroclysis study where the pretest probability of Crohn disease is high. A recent prospective comparison of methylcellulose double-contrast barium enteroclysis to capsule endoscopy with review of the literature has shown that air enteroclysis depicts mucosal details better than does methylcellulose double-contrast enteroclysis because of the "washout" effect of methylcellulose on superficial mucosal features. Recent articles have shown that air enteroclysis compares favorably with wireless capsule endoscopy and double-balloon endoscopy in the diagnosis of mucosal abnormalities of the small bowel. This article describes the authors' technique of performing air double-contrast enteroclysis, its clinical indications, and its pitfalls.
Assuntos
Sulfato de Bário , Dióxido de Carbono , Doença de Crohn/diagnóstico , Intestino Delgado , Metilcelulose , Endoscopia por Cápsula/métodos , Meios de Contraste , Doença de Crohn/diagnóstico por imagem , Doença de Crohn/patologia , Humanos , Intestino Delgado/diagnóstico por imagem , Intestino Delgado/patologia , Imageamento por Ressonância Magnética/métodos , Tomografia Computadorizada por Raios X/métodosRESUMO
OBJECTIVE: To compare the safety and patient-reported effectiveness of two regimens for conscious sedation during enteroclysis. MATERIALS AND METHODS: We surveyed two groups of outpatients and retrospectively reviewed procedure records for conscious sedation and complications. Patients were divided into Group One (received sedative/amnesic diazepam), and Group Two, (received amnesic/sedative, midazolam and analgesic fentanyl). RESULTS: All enteroclyses were successfully completed; there were no hospital admissions due to complications. In Group One (n=106), mean dose of diazepam was 12.7 mg. 25% had oxygen desaturation (n=25), and post-procedure vomiting without aspiration (n=1). 56% of outpatients completed phone surveys, and 68% recalled procedural discomfort. In Group Two (n=45), mean doses were 3.9 mg midazolam and 108 mcg fentanyl. 31% had desaturation (n=13), and post-procedure vomiting without aspiration (n=1). 87% had only a vague recall of the procedure or of any discomfort. CONCLUSION: A combination of amnesic and fentanyl prevented the recall of discomfort of nasoenteric intubation and infusion in most patients who had enteroclysis compared to diazepam. Most of the patients would undergo the procedure again, if needed.
Assuntos
Sedação Consciente/métodos , Diazepam/administração & dosagem , Fentanila/administração & dosagem , Intestinos/diagnóstico por imagem , Midazolam/administração & dosagem , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Hipnóticos e Sedativos/administração & dosagem , Masculino , Pessoa de Meia-Idade , Radiografia , Resultado do TratamentoRESUMO
PURPOSE: To compare results of capsule endoscopy with those of barium enteroclysis or CT enteroclysis. METHODS: Retrospective review of hospital records revealed 65 patients who had an enteroclysis and small bowel capsule endoscopy. The diagnostic yield of capsule endoscopy was compared with the enteroclysis using Fisher's exact test. RESULTS: The main indications were obscure gastrointestinal bleeding (n = 37) and suspected Crohn disease (n = 17). Radiologic studies included CT enteroclysis (n = 30), and fluoroscopic barium enteroclysis with carbon dioxide (n = 18) or with methylcellulose (n = 17). Capsule endoscopy had a higher diagnostic yield (8/17) compared to barium-methylcellulose cellulose enteroclysis (1/17) (P = 0.02). The diagnostic yield of capsule endoscopy was not significantly different compared with barium-carbon dioxide (12/18 vs. 10/18) enteroclysis or with CT enteroclysis (9/30 vs. 8/30). Vascular lesions were better assessed with capsule endoscopy. However, the CT enteroclysis found more lesions in patients with chronic abdominal pain. CONCLUSION: Barium-carbon dioxide enteroclysis and CT enteroclysis have similar diagnostic yields for small bowel disease compared to capsule endoscopy. Barium methylcellulose has an inferior diagnostic yield.
Assuntos
Endoscopia por Cápsula , Enteropatias/diagnóstico , Intestino Delgado , Tomografia Computadorizada por Raios X , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Sulfato de Bário , Criança , Meios de Contraste , Feminino , Fluoroscopia , Humanos , Enteropatias/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Estudos RetrospectivosRESUMO
Computed tomographic (CT) enteroclysis is a hybrid technique that combines the methods of fluoroscopic intubation-infusion small-bowel examinations with that of abdominal CT. The use of multidetector CT technology has made this a versatile examination that has evolved into two distinct technical modifications. CT enteroclysis can be performed by using positive enteral contrast material without intravenous contrast material and neutral enteral contrast material with intravenous contrast material. CT enteroclysis has been shown to be superior to other imaging tests such as peroral small-bowel examinations, conventional CT, and barium enteroclysis, except in the demonstration of early apthous ulcers of Crohn disease. CT enteroclysis is complementary to capsule endoscopy in the elective investigation of small-bowel disease, with a specific role in the investigation of Crohn disease, small-bowel obstruction, and unexplained gastrointestinal bleeding.
Assuntos
Meios de Contraste , Enteropatias/diagnóstico por imagem , Intestino Delgado/diagnóstico por imagem , Tomografia Computadorizada por Raios X , Meios de Contraste/administração & dosagem , Humanos , Injeções IntravenosasRESUMO
OBJECTIVE: The purpose of our study was to review how commonly performed radiologic examinations compare with capsule endoscopy in the investigation of small-bowel diseases, to analyze the limitations of capsule imaging, and to propose an algorithm for use of specific radiologic examinations to complement wireless capsule endoscopy. CONCLUSION: The diagnostic yield of capsule endoscopy is superior to that of radiologic examinations except air double-contrast enteroclysis for mucosal details. Radiologic investigations find new applications in clinical practice by complementing capsule endoscopy to overcome its limitations.
Assuntos
Endoscopia por Cápsula , Enteropatias/diagnóstico , Intestino Delgado , Tomografia Computadorizada por Raios X , Humanos , Enteropatias/diagnóstico por imagemRESUMO
CT enteroclysis overcomes the individual deficiencies of both barium enteroclysis and conventional CT and combines the advantages of both into one technique whose clinical applicability has been simplified and made more reliable with multidetector CT technology. This article examines the techniques of CT enteroclysis and presents an overview of its clinical applications relative to other methods of small bowel imaging.
Assuntos
Enteropatias/diagnóstico por imagem , Intestino Delgado/diagnóstico por imagem , Tomografia Computadorizada por Raios X/métodos , Endoscopia por Cápsula , Meios de Contraste/administração & dosagem , Humanos , Enteropatias/patologia , Intestino Delgado/patologiaRESUMO
OBJECTIVE: Our objective was to report the CT features of biliopancreatic limb (afferent loop) obstruction. CONCLUSION: Acute biliopancreatic limb obstruction has typical CT features. Given its high morbidity and rate of reoperation, it is useful to make this specific diagnosis instead of reporting the findings as postoperative small bowel obstruction.
Assuntos
Desvio Biliopancreático/efeitos adversos , Obstrução Intestinal/diagnóstico por imagem , Obstrução Intestinal/etiologia , Tomografia Computadorizada por Raios X , Doença Aguda , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos RetrospectivosRESUMO
OBJECTIVE: Gastrointestinal complications of major abdominal surgery often require radiologic assessment. The purpose of this article is to review the expected imaging findings and complications after commonly performed gastric and pancreatic surgery. CONCLUSION: It is important to understand the postsurgical anatomy to avoid misinterpreting an expected postoperative finding as a complication. Postoperative complications can be categorized as being related to adhesions, anastomosis, an enteric connection, and abnormal bowel position.
Assuntos
Abdome Agudo/diagnóstico por imagem , Abdome Agudo/cirurgia , Procedimentos Cirúrgicos do Sistema Digestório , Enteropatias/diagnóstico por imagem , Enteropatias/cirurgia , Intestino Delgado/diagnóstico por imagem , Complicações Pós-Operatórias/diagnóstico por imagem , Radiografia Abdominal , Anastomose Cirúrgica , Humanos , Tomografia Computadorizada por Raios XRESUMO
OBJECTIVE: Surgery is increasingly undertaken for intractable chronic pancreatitis. We evaluated the postsurgical anatomy and complications of surgical options including Whipple, Puestow, Frey's, and Beger's procedures. CONCLUSIONS: Knowledge of postsurgical anatomy is important to avoid misdiagnosing expected anatomy as complications on CT examinations. It is important to carefully assess the upper abdominal arteries to detect subtle but potentially lethal complications.
Assuntos
Pancreatite/cirurgia , Complicações Pós-Operatórias/diagnóstico por imagem , Tomografia Computadorizada por Raios X , Angiografia , Doença Crônica , Humanos , Pancreatite/diagnóstico por imagem , Período Pós-Operatório , Radiografia Abdominal , Sensibilidade e EspecificidadeRESUMO
Obesity is rapidly becoming the most important public health issue in USA and Europe. Roux-en-Y gastric bypass is now established as the gold standard for treating intractable morbid or super obesity. We reviewed the imaging findings following this surgery in 234 patients. In this pictorial essay we present the CT and upper gastrointestinal contrast study appearances of the expected postoperative anatomy as well as a range of abdominal complications. The complications are classified into leaks, fistula and obstruction. Postoperative gastric outlet and small bowel obstruction can be caused by anastomotic stenosis, mesocolic tunnel stenosis, adhesions, stomal ulcer, obturation, intussusception and internal or external hernia. Small bowel obstruction may be of a simple, closed loop and/or strangulating type. The radiologist should be able to diagnose the type and possible cause of obstruction.
Assuntos
Anastomose em-Y de Roux , Derivação Gástrica/métodos , Gastroenteropatias/diagnóstico por imagem , Obesidade Mórbida/cirurgia , Complicações Pós-Operatórias/diagnóstico por imagem , Feminino , Gastroenteropatias/epidemiologia , Humanos , Incidência , Masculino , Complicações Pós-Operatórias/epidemiologia , RadiografiaRESUMO
Small bowel obstruction is a common clinical condition, often presenting with signs and symptoms similar to those seen in other acute abdominal disorders. The diagnosis and treatment of this dynamic process continues to evolve. The imaging approach in the work-up of patients with known or suspected small bowel obstruction and the timing of surgical intervention in this disease have undergone considerable changes over the past two decades. This article examines the changes related to the use of imaging technology in the diagnosis and management of patients with small bowel obstruction. The meaning of frequently used but poorly defined terms in describing intestinal obstruction is clarified and illustrated.
Assuntos
Diagnóstico por Imagem , Obstrução Intestinal/diagnóstico , Intestino Delgado , Meios de Contraste , Diagnóstico Diferencial , Humanos , Obstrução Intestinal/etiologia , Obstrução Intestinal/terapia , Imageamento por Ressonância Magnética/métodos , Radiografia Abdominal , Tomografia Computadorizada por Raios X/métodosRESUMO
As the primary method of investigating the small bowel, enteroclysis remains a technique in evolution. Technical refinements have made the examination faster to perform, better tolerated by patients, and easier to interpret. More recently, its essential principle of volume challenge has been combined with the tremendous advantage of CT cross-sectional imaging with multiplanar reformatting to give rise to the exciting new techniques of CT enteroclysis and MR enteroclysis (see separate reviews in this issue). Through improvements in methodology and advancements in technology, the future of enteroclysis looks bright indeed.
Assuntos
Enteropatias/diagnóstico por imagem , Intestino Delgado , Tomografia Computadorizada por Raios X/métodos , Meios de Contraste/administração & dosagem , Humanos , Intubação GastrointestinalRESUMO
Currently, CT-E is not recommended as the first-line examination in patients when mucosal detail is required. Double-contrast barium air enteroclysis has advantages in demonstrating small mucosal abnormalities. The authors find CT-E of value in the work-up of patients with symptoms of intermittent small bowel obstruction, particularly those with a history of prior abdominal surgery; in the further work-up of selected patients with high-grade obstruction in whom general surgeons prefer initial conservative management (immediate postoperative small bowel obstruction, patients with history of prior abdominal surgery for malignant tumor, history of radiation treatment, and possible internal extraintestinal fistulae); in looking for complications of small bowel Crohn's disease; and in the patient with unexplained anemia or gastrointestinal bleeding. In a series of patients who had both abdominal CT and barium enteroclysis done, each examination provided unique and complimentary diagnostic information. Because CT-E combines the advantages of both methods of examination, is it the optimum imaging work-up in the investigation of small bowel disease? Further research and clinical experience will define the precise role of CT-E in the investigation of small bowel disease. Experience with this method of examination is limited to a few institutions, performed by investigators with interest in small bowel diseases. The addition of cross-sectional display and multiplanar reformatting made possible by multidetector-row helical CT to enteral volume change and the use of multifunctional nasointestinal catheters make CT-E an important tool in the investigation of small bowel disease. Experience has shown the increased reliability of any method of examining the small bowel that challenges intestinal wall distensibility by fluid enteral volume infusion.
Assuntos
Enteropatias/diagnóstico por imagem , Intestino Delgado , Tomografia Computadorizada por Raios X/métodos , Meios de Contraste/administração & dosagem , HumanosRESUMO
The diagnosis and treatment of small bowel obstruction continue to evolve. The imaging approach in the work-up of patients with known or suspected small bowel obstruction and the timing of surgical intervention in this disease have undergone considerable changes over the past two decades. This article examines the current concepts related to the use of imaging technology in the diagnosis and management of patients with small bowel obstruction. The meaning of frequently used but poorly defined terms in describing intestinal obstruction is clarified and illustrated.
Assuntos
Obstrução Intestinal/diagnóstico , Intestino Delgado , Sulfato de Bário , Meios de Contraste , Humanos , Obstrução Intestinal/diagnóstico por imagem , Imageamento por Ressonância Magnética/métodos , Radiografia Abdominal , Tomografia Computadorizada por Raios X/métodosRESUMO
The small bowel is subject to a variety of surgical interventions for the treatment of a broad spectrum of disease processes. Most operative procedures applied to the small bowel are straightforward techniques encumbered by few complications, whereas other procedures are considerably more complex and can be associated with significant postoperative morbidity. Familiarity with the anatomic alterations related to the various operations is essential, both for evaluation of early postoperative complications and those abnormalities that manifest late in the postoperative course. The surgeon and radiologist should carefully coordinate clinical suspicion with the strengths of the various imaging modalities to optimize postsurgical assessment and provide timely and accurate diagnosis. Enteric anastomoses, the different forms of enterostomy, and the varied constructions of small bowel pouches and reservoirs are each associated with unique anatomy and therefore optimal techniques of assessment. Small bowel contrast studies such as enteroclysis--including its recent modification, CT enteroclysis--and CT imaging represent the primary modalities for imaging of the postoperative bowel and its related abnormalities. Small bowel transplantation continues to progress as a realistic treatment for intestinal failure, and the role of diagnostic imaging in these unique and challenging patients is evolving.