Stent placement for benign pancreatic diseases: correlation between ERCP findings and clinical response.

OBJECTIVE: We performed a study to determine if the appearance of the pancreatic duct on ERCP before and after placement of pancreatic duct stents correlates with the therapeutic response in patients treated for impaired pancreatic drainage. MATERIALS AND METHODS: Findings in 29 consecutive patients with a variety of benign pancreatic diseases in whom pancreatic stents were placed and subsequently removed within a 3-year period were reviewed retrospectively. Early (1-5 days) and late (1-3 months) clinical outcomes after stent placement were assessed. These findings were correlated with a blinded interpretation of ERCP findings (Cambridge criteria were used) before and after stent placement. RESULTS: ERCP findings before stent placement were normal in 10 patients. At the end of stent therapy, ERCP showed changes associated with chronic pancreatitis in all 10; five had focal narrowing at the tip of the stent. Subsequent ERCP studies in five of these 10 patients showed that ductal changes induced by stents diminished after stent removal. Of the 19 patients with abnormal findings on ERCP at the time of stent placement, ERCP at the end of stent therapy showed some improvement in seven patients, no change in eight, and deterioration in four. Changes seen on ERCP had no statistically significant correlation with clinical outcome (p = .36). CONCLUSION: Our findings show that pancreatic duct stents can induce abnormalities on ERCP indicative of chronic pancreatitis. However, diminution of these abnormalities after stent removal in some patients suggests that these changes may be due to edema rather than to fibrosis. Ductal changes seen on ERCP are not a useful guide for determining the degree of response to pancreatic stents.

Plasma viscosity and C-reactive protein after total hip and knee arthroplasty.

We studied the changes in plasma viscosity and C-reactive protein to establish normal values after total hip or knee arthroplasty. Viscosity decreased from 1.68 (+/- 0.017) to 1.57 (+/- 0.014) on the first postoperative day and thereafter rose to 1.60 (+/- 0.019), 1.75 (+/- 0.015), and 1.74 (+/- 0.011) on the third, seventh and fourteenth days respectively. Six to eight weeks after operation it had returned to pre-operative levels. A viscosity above the upper limit of the laboratory range, obtained more than two months after operation, may be considered as abnormal. The C-reactive protein level increased significantly on the first postoperative day and then decreased from a peak on the second day, attaining nearly normal levels at six to eight weeks after operation. It may be a more sensitive indicator of deep postoperative infection than plasma viscosity.

CT of fundoplication.

To determine the CT findings postfundoplication, we retrospectively compared CT in 22 postfundoplication patients with CT in 22 patients with unrepaired hiatal hernias and gastroesophageal (GE) junction abnormalities and 24 patients with gastric or esophageal carcinoma involving the GE junction. Seventeen of the 22 postfundoplication patients had undergone a Nissen procedure. Of the 22 patients, 11 had esophageal dilatation, 14 had GE junction masses, 4 had esophageal wall thickening, 7 had surgical clips, and none had hepatic metastases or upper abdominal lymphadenopathy. Statistically, on CT, postfundoplication patients are more likely to have a GE junction mass (p = 0.023) and least likely to have wall thickening (p = 0.021). Nonetheless, because the findings occur frequently in each group, they are not diagnostic in the individual patient. However, 11 of 12 post-Nissen masses had the unique finding of an oval or linear central fat density within the mass. This finding was absent in the other postfundoplication masses and in those patients with repaired hiatal hernia or tumor. We conclude that pseudomasses occur on CT postfundoplication and can be indistinguishable from hiatal hernias and GE junction neoplasms unless a central fat density is present.

Pneumatosis intestinalis. Surgical management and clinical outcome.

Pneumatosis intestinalis (PI) occurs in a wide variety of patients, some of whom require urgent surgery, while others can be observed with resolution of symptoms and radiographic findings. During 1 year, 27 patients with PI were prospectively evaluated for clinical, laboratory, and radiographic features that would be useful in predicting the need for surgery, the pathologic findings, and patient outcome. Sixteen of the twenty-seven patients underwent laparotomy, with only one negative exploration. Of the 11 patients not explored, there were two deaths in moribund patients. Seven of nine patients with jejunostomy tubes, recent gastrointestinal anastomoses, inflammatory bowel disease, lactulose therapy, or chemotherapy who did not have clinical evidence of an acute surgical abdomen or metabolic acidosis survived without surgery (two deaths unrelated to the gastrointestinal tract). Patients presenting with bowel obstruction and PI required surgery in seven of nine cases, did not have necrotic bowel, and had 11% mortality. Eight patients with ischemic bowel had a 75% mortality rate, despite surgery. Patients with PI and clinical evidence of bowel obstruction or ischemia usually require urgent surgery, while asymptomatic patients without metabolic acidosis can be safely observed.

Gastrointestinal complications of pancreatitis.

Supine and upright films of the abdomen are usually the first imaging procedures in the evaluation of patients with suspected acute pancreatitis and may document calcific pancreatitis, inflammatory masses, abscesses, or obstruction. Appropriate barium or water-soluble contrast examination of the upper GI tract may provide an accurate indication of upper GI tract obstruction as well as document gastric varices that may occur as a complication of pancreatitis. Appropriate contrast examinations of the colon are important in documenting the extent of inflammatory changes of the colon, which may include perforation and necrosis. Accurate and expeditious documentation of these colonic complications is important in planning appropriate surgical therapy.

Diagnosis of acute colonic diverticulitis: comparison of barium enema and CT.

The contrast enema and CT studies in 102 patients with a clinical diagnosis (41%) or surgically confirmed (59%) diagnosis of colonic diverticulitis were reviewed retrospectively to determine the sensitivity of the two techniques. Combined results from all patients showed that the contrast enema was correct in 77% of patients. The contrast enema was falsely negative in 15% and was indeterminate in 7%. The CT examination was diagnostic in 41%, consistent with the diagnosis of diverticulitis in 38%, and falsely negative in 21% of patients. Both CT and contrast enemas were more accurate in patients with severe disease requiring surgery. No complications occurred from 109 enemas performed. Patient management was altered in only one patient as a result of the additional information provided by CT. The contrast enema should remain the initial and routine examination for the evaluation of patients with suspected diverticulitis. CT should be reserved for patients who are unable to have an adequate contrast enema, those with suspected distant or diffuse abdominal abscess, those who are unresponsive to medical therapy, and those who are candidates for percutaneous drainage.

Adult esophageal candidiasis: a radiographic spectrum.

With the increasing use of cancer chemotherapy and organ transplantation requiring immunosuppressive therapy, and with the incidence of immunodeficiency states such as AIDS increasing, it is to be expected that candida esophagitis will occur with increasing frequency. Though fiberoptic endoscopy is a more specific and more sensitive approach to the diagnosis of candida esophagitis than barium esophagography, it is also more invasive, and many patients will continue to be examined radiologically, at least initially. The radiologist continues, therefore, to play a significant role in suggesting the diagnosis and it is incumbent on him to familiarize himself with the spectrum of common and unusual radiographic manifestations of this disease.

Optimal cholangiographic technique for detecting bile duct stones.

Twenty-eight patients with proven bile duct stones were evaluated during either operative or T-tube cholangiography. Two radiographs were obtained for each patient without changing patient position between films. The first was performed with low peak kilovoltage (75-80 kVp) and 15% iodinated contrast medium and the second with high kVp (110) and 38% iodinated contrast. Seven radiologists evaluated the radiographs individually and in matched pairs for ductal filling, ductal penetration, motion unsharpness, overall quality, and stone detectability. The high-kVp radiographs were rated significantly better overall than the low-kVp studies (p less than 0.001) for all five criteria. In the second evaluation, which compared the pairs from the same patients, the 28 high-kVp radiographs were considered superior to the 28 low-kVp studies by the radiologists in almost two-thirds of the comparisons (ductal filling, 68%; penetration, 59%; less motion unsharpness, 65%; overall quality, 77%; stone detection, 62%). On the basis of the results of this study, high-kVp technique with full-strength contrast medium for operative and T-tube cholangiography is recommended.

Diagnostic imaging of abdominal fluid collections and abscesses.

With today's advanced technology, the clinician and radiologist have a number of techniques with which to evaluate the abdomen for fluid collections and/or abscesses. Three points are clear from the plethora of literature concerning this subject: the need to individualize the clinical and imaging approach to each patient suspected of an abnormal fluid collection or abscess, the need to individualize the imaging procedure based upon what is done best at the institution, and the need for percutaneous aspiration of all fluid collections for diagnosis. No single imaging test is totally sensitive or specific for the detection of an infected fluid collection. Overall, CT probably does provide the most accurate means to detect an intra-abdominal abscess. Because of this, and because it is less operator dependent than ultrasound, CT is used most often as the procedure of choice at our institution.

The radiologic evaluation of gross cecal distension: emphasis on cecal ileus.

A retrospective review of plain abdominal radiographs in 46 patients with gross cecal distension (greater than 10 cm) was performed. In 25 (54%) of 46 patients, the cecum was dilated out of proportion to the rest of the colon and was rotated anteromedially. The term cecal ileus is used to describe this situation. Five (20%) of 25 patients with cecal ileus developed perforation. Four of these patients died as a result of the perforation. The risk of perforation was related more to duration of cecal distension than to absolute cecal size. Aggressive decompressive measures, including consideration of cecostomy, appear warranted in patients with gross cecal distension, especially when it is dilated out of proportion to the rest of the colon and has persisted for several days.

Revascularized jejunal graft replacing the cervical esophagus: radiographic evaluation.

Free jejunal autotransplantation is a successful surgical procedure for reconstruction of the cervical esophagus in treatment of carcinoma of the pharyngoesophagus. Radiographic assessment is essential in the postoperative evaluation of these patients. Twenty-two patients with jejunal autotransplants have been followed with radiographic examinations. Eleven of them have had normal postoperative studies. Acute and delayed complications characterized by anastomotic leaks, fistulae, and strictures have been observed in the other 11 patients. The techniques of radiographic examination and the radiographic features of the normal graft and associated complications are described.

Nonspecificity of barium enema findings in acute appendicitis.

Barium enema examination is a well known and useful adjunctive technique for the diagnosis of acute appendicitis when its clinical presentation is atypical. The combination of a mass effect on the cecum and nonfilling of the appendix have been considered virtually pathognomonic radiographic findings. These appearances on barium enema examination may also be encountered in patients with small-bowel obstruction, acute enterocolitis, pelvic hemorrhage and adhesions, and pelvic inflammatory disease. In three of five cases, these radiographic findings contributed to the decision to perform laparotomy, at which a histologically normal appendix was removed. The value of the barium enema examination in suspected but atypical acute appendicitis must be tempered by the recognition that occasionally other diseases with acute presentations produce similar findings.

Computed tomography of pneumatosis intestinalis.

Four cases of pneumatosis intestinalis detected by computed tomography (CT) are described. Plain abdominal films obtained on the same day as CT failed to show pneumatosis in three of the four cases. The CT appearances characteristic of pneumatosis intestinalis are cystic, linear, or curvilinear gas collections in the periphery of distended, partly fluid-filled loops of bowel. Two of the four cases had underlying bowel infarction. Evidence of pneumatosis should be carefully looked for in patients with acute abdominal pain referred for CT examination. Computed tomography may be a useful modality for the early diagnosis of bowel ischemia when plain abdominal films are noncontributory.

Can ultrasonic examination of the pancreas and gallbladder follow a barium UGI series on the same day?

Ultrasonic examinations of the pancreas and gallbladder are currently not performed after a barium UGI series until all of the barium has cleared the gastrointestinal tract (12-48 hours). By giving water one hour after a barium UGI series and scanning the patient in an upright position, using the stomach as an acoustic window, we have been successful in visualizing the pancreas in all 14 of the volunteers studied. Our visualization of the pancreas and gallbladder was as good after the UGI series as it was prior to the ingestion of barium in every case. The use of this technique can expedite the evaluation of patients in whom both upper abdominal ultrasonic and barium UGI series are indicated.

The value of the preoperative barium-enema examination in the assessment of pelvic masses.

The value of the barium-enema examination in the assessment of pelvic masses was studied in 44 patients. Findings from those barium-enema examinations and from pathological specimens from 37 patients who had malignant tumors and seven patients who had endometriosis were retrospectively analyzed to determine if the barium-enema examination is useful in differentiating extrinsic lesions with and without invasion of the colon. None of the 12 patients who had extrinsic lesions had any of the criteria that indicated bowel-wall invasion. These criteria included fixation and serrations of the bowel wall in all patients with invasion, and ulceration and fistulization in those patients who had complete transmural invasion. In patients with pelvic masses, the preoperative barium-enema examination may be useful to the surgeon in planning surgery and in preparing the patient for the possibility of partial colectomy or colostomy.

High kVp vs. low kVp for T-tube and operative cholangiography.

Based on several considerations, high kVp and high contrast agent concentration should produce better-quality operative and T-tube cholangiograms than the currently recommended low kVp and low contrast agent concentration. To test this theory, two kinds of studies were performed. In a laboratory phantom, the influence of kVp and contrast agent concentration on detectability of different size phantom stones was evaluated. High kVp and high contrast agent concentration (110 kVp, 38% iodine) were also compared with low kVp and low contrast agent concentration (75 kVp, 15% iodine) in 62 patients undergoing operative or T-tube cholangiography. Almost all phantom stones were well shown with all kVps and iodine concentrations. As the kVp was raised there was a mild decrease in stone detectability but this decrease was partially corrected by raising the iodine concentration. Overall stone detectability with high kVp and high contrast agent concentration technique was better than or similar to the currently recommended low kVp and low contrast agent concentration technique. Evaluation of the direct cholangiograms by five radiologists revealed that the high kVp, high contrast agent concentration studies were superior or similar to the low kVp and low contrast agent concentration radiographs in 70% of the cases. Based on these results high kVp (100-110) and a high contrast agent concentration (38%) are recommended for direct cholangiography.