Common bile duct obstruction by free floating tumor.

UNLABELLED: Tumors usually spread by local invasion or by vascular or lymphatic metastases. We report six patients in whom tumor cells were shed into the common bile duct with resulting obstruction. The three men and three women had jaundice and upper abdominal discomfort. Jaundice was intermittent in four patients. Preoperative total serum bilirubin ranged from 2.5 to 16.1 mg/dl; alkaline phosphatase ranged from 221 to 605 IU/1. Ultrasound showed a dilated gallbladder [GB] in five patients with dilated intrahepatic ducts in three and stones in only one. ERCP showed a single filling defect in two of three patients and multiple defects in one. PTC showed multiple defects in one patient. At operation a thick gelatinous tissue fragment or clot was seen in the common bile duct of each patient. Frozen section identified tumor tissue in all. The source was GB carcinoma [2], GB adenomyoma [1], hepatic metastases of colon cancer [2] and common bile duct cancer [1]. Treatment consisted of pancreaticoduodenectomy [2], including one for GB cancer, left hepatic lobectomy [1], choledochoduodenostomy [1], common duct exploration with T-tube insertion [1] and cholecystectomy [1]. One patient with metastatic colon cancer and another with gallbladder cancer died within one year of operation. The other four are alive from 2 to 4 years later. CONCLUSION: Benign or malignant tumors within the hepatobiliary tree can shed tissue into the common bile duct which can cause biliary obstruction. Any tissue fragment found in the common bile duct should be evaluated by frozen section. Recognition of this mode of tumor spread is needed for appropriate therapy of the underlying benign or malignant tumor.

Gallbladder wall thickening in preeclampsia.

Sonographic examination of the gallbladder in two patients with preeclampsia and right upper quadrant pain demonstrated notable thickening of the gallbladder wall. The sonographic abnormality and clinical symptoms completely resolved after delivery and/or medical management of the preeclampsia. This finding is probably secondary to the hypoalbuminemia characteristic of preeclampsia and should not be mistaken for intrinsic gallbladder disease.

Evaluation of superior vena cava syndrome by axial CT and CT phlebography.

Transverse axial computed tomography (CT) has been combined with CT digital phlebography to study nine patients with superior vena cava syndrome. Six were due to malignancy, two were secondary to benign disease, and one was a paraneoplastic manifestation. This combined CT approach successfully identified the abnormal morphology of the superior vena cava, demonstrating external compression, encasement, or intraluminal thrombus in all patients and the collateral venous channels in eight. The efficacy and advantages of this technique are discussed. This technique is a rapid, informative, and cost-effective method for the workup of superior vena cava syndrome. The CT digital phlebogram, however, is not successful in regularly and optimally opacifying the normal superior vena cava because of the limited amount of contrast material, dilution effect of the nonopacified incoming flow from the jugular and azygos veins, and the lack of image enhancement from the CT digital scanograms.

Metastatic leiomyosarcoma of the kidney with spontaneous perirenal hemorrhage.

Spontaneous subcapsular or perirenal hemorrhage is most often associated with a primary renal neoplasm which may be malignant or benign. No case of metastasis to the kidney causing such hemorrhage has been reported. The patient presented here had spontaneous perirenal hemorrhage due to metastasis to the kidney from a leiomyosarcoma of the uterus.

Computed tomographic demonstration of anomalous inferior vena cava with azygos continuation.

A case of anomalous inferior vena cava with azygos continuation first diagnosed by computed tomography (CT) and later confirmed by venography is presented. In addition to identifying the dilated azygos vein in the chest, CT can determine the direction of flow in the vein by means of a bolus contrast medium injection. Once this is established, a search for the etiology of the dilated vein can be directed to the appropriate anatomic area.

Computed tomography in the evaluation of liver disease in cystic fibrosis patients.

The results of a study of cystic fibrosis patients with liver disease using computed tomography are reported. The findings are described, and a discussion of their significance and place in patient investigation is offered.

Pancreatic pseudotumors: computed tomography.

Although pancreatic disease is suspected initially by historical or biochemical findings, the nature of the pathologic process in the past was frequently established only through invasive procedures. Inferences can be drawn from routine roentgenologic examinations, but visualization of the pancreas has only recently been achieved. Of the currently available noninvasive imaging procedures, computed tomography, in our opinion, is the screening procedure of choice. Care in the interpretation of pancreatic masses must be exercised since some of the findings can be attributed to anatomic variants, normal adjacent structures, or other neighboring pathologic processes.

Visualization of the lateral edge of the liver in ascites.

Medial displacement of the liver was observed in 35 cases of ascites using plain radiographs, total-body opacification, tomography, radionuclide imaging, peritoneography, and/or ultrasonography. In 16 cases the displaces liver was seen on plain radiographs. Separation of the liver and kidney was seen on ultrasonograms in every case; it was increased by addition of increments of fluid in patients undergoing peritoneal dialysis. Since the liver is surrounded by fluid, an interface between it and the extraperitoneal fat cannot account for the displacement seen on plain radiographs: rather, this is the result of a difference in density between liver and fluid.

Ultrasonically guided percutaneous biopsy of peripheral pulmonary masses.

Ultrasonically guided percutaneous biopsy and aspiration of solid and cystic structures in the abdomen, neck, and pericardial space are common practice. The technique may be utilized for biopsy of peripheral pulmonary masses in contact with the chest wall, in order to assure accurate placement of the needle in the center of the mass, reduce the risk of pneumothorax, and eliminate the exposure to radiation that occurs with fluoroscopic guidance. Four patients had successful biopsies in this manner, without complications. Histologic studies revelaed malignant neoplasms in three and lipoid pneumonia in one.