Mirizzi syndrome--a report of 3 cases with a review of the present classifications.

We report three cases of Mirizzi syndrome, two with external compression of the common hepatic duct and another with cystobiliary fistula. All patients presented with jaundice. The diagnosis was suggested by ultrasonography and confirmed by endoscopic retrograde cholangiography (ERC). All three had the stones removed surgically, one through a choledochotomy, another through an opening in the gall bladder and the third at the time of subtotal cholecystectomy. We would like to propose a simple classification of Mirizzi syndrome, based on surgical procedures necessary for the correction of the pathological anatomy. If it involves the removal of calculi with some form of cholecystectomy, we consider it as Type I, whereas Type II involves the construction of a hepaticojejunostomy apart from the removal of calculi.

Gangliocytoma--magnetic resonance imaging characteristics.

An atypical presentation of a temporal lobe gangliocytoma in an adult female with headaches is reported. Computed tomography showed a hypodense enhancing mass in the right temporal lobe with vasogenic oedema and mass effect. MRI demonstrated a well demarcated mass of low signal on T1W, intermediate signal on PDW, high signal on T2W and homogeneous enhancement on post-gadolinium scan. This case is an addition to the current literature for the characteristic MR features of a ganglion cell tumour.

Suprarenal cystic masses: unusual causes.

Two cases of large suprarenal cystic masses with extremely rare histological diagnoses of adrenal neurogenous choristoma and multicystic intrarenal neuroblastoma are presented. Ultrasonographic, CT scanning and histological features are described and differential diagnosis discussed.

Recurrent pyogenic cholangitis: 'sump syndrome' following choledochoduodenostomy.

An uncommon and late complication of side-to-side choledochoduodenostomy (CDD), the 'sump syndrome', developed in a patient 4 years after surgery. Recurrent right upper abdominal pain, fever with chills and rigors and latterly, mild jaundice made her seek repeated hospital admissions which were treated successfully with antibiotics. During the last admission, ultrasonography, endoscopic retrograde cholangiography (ERC), computerized scanning (CT) and hepatic iminodiacetic acid (HIDA) scan using Tc99m confirmed multiple intrahepatic calculi with proximal dilatation, debris in the distal blind segment and delayed excretion through the CDD. At surgery, the choledochoduodenostomy was taken down and a Rouxen-Y hepaticojejunostomy (RHJ) was fashioned after ductal clearance. The closed end of the Roux loop was placed subcutaneously for subsequent percutaneous access for cholangiography and removal of calculi. She is asymptomatic and well 28 months after surgery.

Diffuse axonal injury A clinical and computerised tomography study of 128 patients.

A study of clinical, computerised tomography (CT) profile and outcome was made of 128 patients, diagnosed to have diffuse axonal injury based on CT criteria. The mean age was 26 years. A lucid interval was present in 37 patients and hypoxia and/or hypotension was present in 43 patients. The depth of "marker lesions" in CT correlated with Glasgow Coma Score (GCS) (p<0.02) and duration of coma (p<0.01). The presence of associated intracranial haematoma >25 ml portended an adverse outcome. A logistic regression analysis revealed age, GCS, state of perimesencephalic cisterns and pupillary dilation to be independent predictors of poor outcome. Residual sequelae (focal deficits, cognitive deficits, postconcussion syndrome) were evident in nearly half of patients with diffuse axonal injury (DAI) and a lucid interval.

Gall bladder tumour, choledochal cyst and an anomalous pancreatico-biliary junction.

This report highlights the association of a tumour in an acalculous gall bladder with an anomalous pancreatico-biliary junction (PBJ) and a type IVa choledochal cyst. Cholecystectomy and Rouxen-Y hepatico-jejunostomy (RHJ) was performed after division of the common bile duct (CBD) and excision of the dilated segment. The details of the case are presented and the role of an abnormal PBJ in gall bladder carcinogenesis is discussed.

Ascarid worms causing recurrent cholangitis in a patient with an obstructing ampullary tumour.

This is a report of a 57-year-old Malay lady who presented with recurrent episodes of cholangitis and septicaemia. A dilated biliary tree caused by a stenosing periampullary tumour was found to contain adult round worms. A pancreatico-duodenectomy was performed following biliary decompression. Ascarid worms are a rare cause of cholangitis in malignant biliary obstruction.

Neuroblastoma and diagnostic imaging.

To assess the utility of the current imaging modalities, a six-year retrospective study was conducted from May 1985 through April 1991 on 11 patients with histopathologically confirmed neuroblastoma. There were four males and seven females. Median age at presentation was six years. All patients underwent intravenous urography (IVU), abdominal ultrasonography (US), skeletal surveys and bone marrow aspiration. Computed tomographic (CT) scanning was performed in nine patients and trephine bone biopsy in five. Suprarenal gland was the primary site in six patients, including one bilateral neuroblastoma. Two presented with primary paraspinal mass, one with posterior mediastinal mass, one had a retroperitoneal tumour and one presented as primary cerebral neuroblastoma. IVU showed indirect evidence of suprarenal tumours in five patients. US demonstrated suprarenal mass in six and calcification within the mass in five patients. US also documented retroperitoneal lymphadenopathy in five patients. US-guided fine needle aspiration biopsy was performed in seven patients and it gave correct histological diagnosis in all. CT accurately depicted all the primary tumours and their involvement of the surrounding structures and metastases in the brain and orbits. US proved to be quite accurate in diagnosing primary abdominal tumours despite its limitations but in other sites, CT was of greater help. Solid appearance of a suprarenal mass on US made the diagnosis of neuroblastoma very likely and calcification within the mass further supported the diagnosis.

Multifocal mucus secreting papillary adenocarcinoma of the bile duct causing obstructive jaundice.

We present a 64-year-old Malay lady who had undergone a choledochoduodenostomy (CDD) two years ago for obstructive jaundice. She was admitted with jaundice and underwent ultrasonography, percutaneous transhepatic cholangiography (PTC), endoscopic retrograde cholangio pancreatography (ERCP) and computed tomographic (CT) scanning of the liver and biliary tree. All the investigations confirmed a type IVa choledochal cyst. At operation, the grossly dilated biliary system was packed with a thick mucoid material and the mucosa of the bile ducts was visibly abnormal with scattered nodules. This mucoid material had caused occlusion of the entire biliary tree resulting in obstructive jaundice. To the best of our knowledge, this is probably the first report of obstructive jaundice caused by thick mucus. The peculiar management problems of this case and the risk of malignant change in choledochal cysts are discussed.

The role of computed tomography in the evaluation of retinoblastoma.

To assess the importance of Computed Tomography(CT) in the evaluation of retinoblastoma, we reviewed thirteen cases of retinoblastoma which presented at Hospital University Sains Malaysia, Kelantan, Malaysia, from August 1986 to June 1991. High resolution computed tomography of the orbits was performed in all patients prior to therapy. Nine patients (69%) had unilateral and four (31%) had bilateral retinoblastoma. The interesting features were the remarkably high incidence in the right eye (89%) as compared to the left eye (11%) in unilateral retinoblastoma, and overall predominance of the male population (male to female ratio was 2:1). Computed tomography detected intraocular calcification in 82% of the tumourous eyes. All patients presented at late stages when tumours were of large size. The presence of calcification was not related to the size of the tumour. CT detected calcification in a suspected retinoblastoma with a high degree of accuracy. Computed tomographic evidence of intraocular calcification in children under 3 years of age is highly suggestive of retinoblastoma.