Renal hemangioma: cause of massive hematuria.

Renal hemangiomas are an unusual cause of renal hematuria. Although a preoperative diagnosis of renal hemangioma is not always possible, the diagnosis of this case of marked blood loss from a renal hemangioma was made angiographically. The clinical characteristics of hemangiomas, as well as the use of angiography in the investigation of hematuria, are discussed.

Intestinal and extraintestinal complications of inflammatory bowel disease.

Inflammatory bowel disease has a variety of local and systemic complications that contribute to the morbidity and mortality associated with the disease. The radiologist plays an important role in the evaluation of these complications.

Malignancy complicating inflammatory bowel disease.

There is now general agreement that both ulcerative colitis and Crohn's disease predispose patients to the development of malignancy. Many controversies still remain concerning the incidence of this complication as well as the diagnostic approach to be taken with these patients. This article reviews the topic and examines the contribution the radiologist can make in evaluating the patient with chronic inflammatory bowel disease.

Radiologic evaluation of constipation and anorectal disorders.

This article has outlined the orderly radiographic approach to evaluating the patient who presents with constipation or other anorectal complaints. Defecography alone provides only a visual record of events taking place during defecation, and it seems likely that further understanding of the pathophysiology will require manometric, electromyographic, and proctographic data in those patients. Defecography is potentially more available than these other techniques because every hospital has a fluoroscopy suite. Studies that relate the proctographic findings with other physiologic studies are underway and necessary. More studies relating pre- and postoperative defecography with clinical results are needed.

Metastatic disease involving the gastrointestinal tract.

Secondary involvement of the gastrointestinal tract by malignancies is encountered frequently. It usually reflects a poor prognosis because it is often multicentric and associated with metastases in other organs. Any therapy is usually palliative. Because of this, conventional barium studies or CT is sufficient for diagnosis and can obviate further studies.

Evolution of the technologist specialist in gastrointestinal radiology.

Over the past few years, a program was initiated at the author's institution to train radiologic technologists to perform the fluoroscopic aspect of gastrointestinal examinations. The program was undertaken in an attempt to improve patient flow through the division, as well as in response to the decreasing number of residents being accepted into the radiology program. The results with respect to diagnostic quality of examination, improved patient flow, and patient and resident acceptance have been satisfactory.

Increased frequency of reactions to contrast materials during gastrointestinal studies.

Although there have been several reports of adverse reactions to contrast material during barium gastrointestinal (GI) studies, these are considered highly unusual. During a 27-month period at the author's institution, seven reactions to contrast material occurred during 6,918 colon examinations, and four reactions to contrast material occurred during 11,534 upper GI procedures. This frequency is greater than what has been reported previously. Most reactions were fairly mild, with urticaria and pruritus, although two patients, both with a history of asthma, had severe reactions that required emergency treatment. One patient had similar adverse reactions during both upper and lower GI examinations. Since only two patients received glucagon, this is not believed to be a factor. It is likely that patients react to some additive in the barium suspension. The radiologist must be aware of these complications and be ready to begin appropriate treatment.

Changing concepts of colonic polyps: clinical and radiographic implications.

The relationship of colonic polyps to carcinoma of the colon provides a basis for their importance. Recent advances in the detection of colonic polyps, including double contrast barium examination and colonoscopy, have provided a method for more extensive study of colonic polyps. Studies using these newer techniques indicate that many traditional concepts of colonic polyps were inaccurate. The relationships of polyp size to histology, polyp location to age, and the phenomenon of colon polyp clustering are important to both the immediate treatment of the polyp and to the long-term follow-up of the patient. The use of hemoccult stool screening as a technique for screening for colonic pathology is also of significance to the radiologist. The changing relationships of various parameters of colon polyps bring into question the utility of many of the currently recommended screening procedures for colon pathology. Undoubtedly, this will impact on the practice of radiology.

Limiting overhead views in double-contrast colon examinations does not affect diagnostic accuracy.

A prospective study was undertaken to evaluate whether reducing overhead (technician-performed) films in double-contrast colon examinations had any effect on diagnostic accuracy. Only 4 overhead films were obtained routinely: supine, both decubitus, and prone cross-table rectal views. A high detect rate was maintained, comparable to our accuracy when 7 or 8 overhead films were obtained. Our study confirms that with double-contrast colon examinations, the need for overhead films is diminished. A significant decrease in cost, radiation exposure, and examination time can be obtained. We continued to use this method without any noticeable decrease in diagnostic accuracy.

Reassessing the role of radiology in Hemoccult screening.

During a recent regional screening program, 98 patients with a positive Hemoccult test were evaluated radiographically. Double-contrast barium enema (DCBE) detected all six carcinomas and 92% of 37 polyps. DCBE was also the most cost-effective procedure. Colonoscopy dramatically increased screening costs without providing evidence to support its use in all Hemoccult-positive patients. It is recommended that DCBE be the initial diagnostic test in Hemoccult-positive patients, to be supplemented in selected patients by flexible sigmoidoscopy or colonoscopy depending on the pathology evident on DCBE and on clinical circumstances.

Gastrointestinal carcinomas in renal transplant recipients.

The development of malignancies in renal transplant recipients is well documented. Typically, these are cutaneous tumors or lymphomas. During the past 5 years, we have encountered six patients with documented carcinomas of the gastrointestinal tract, which developed after these patients received renal transplants. These carcinomas developed at an average of 10 years (range 2-16 years) after renal transplantation. There were three carcinomas of the colon, and one each of the esophagus, stomach, and anal canal. In many instances, the patients had examinations prior to transplantation which were normal. Several surveys of transplant recipients indicate there is an increased incidence of gastrointestinal tract malignancies after transplantation. These studies also recommend that screening of the gastrointestinal tract in long-term transplant recipients be performed. Since these patients are often imaged in the radiology department, radiologists must be aware of this possible complication.

Nonspecific radiographic abnormalities in collagenous colitis.

Collagenous colitis (CC) is characterized clinically by a chronic, watery diarrhea. Pathologically, there is a chronic lymphocytic infiltrate with abnormal thickening of the subepithelial collagen layer. This disease occurs predominantly in females, and is more frequent in the elderly. Previous clinical studies suggest that radiographic examination of the colon is of no value in this condition. We reviewed five cases of CC all of whom had colon examination within 2 weeks of the biopsy. Two of our patients showed evidence of mucosal granularity and irregularity of the rectosigmoid on double-contrast barium enema (DCBE). One patient had nodularity of the rectal wall on single-contrast colon examination. Two patients had no inflammatory changes evident on colon examination. These radiographic changes are nonspecific and may be seen in other forms of colitis, particularly ulcerative colitis and nonspecific proctitis.

Achalasia secondary to nongastrointestinal malignancies.

Secondary or "pseudo" achalasia of the esophagus can mimic idiopathic achalasia radiographically and can be difficult to diagnose. Typically, it is due to invasive carcinoma involving the gastroesophageal junction, usually gastric adenocarcinoma. Occasionally, an achalasialike condition can be produced by tumors not involving the gastroesophageal junction. We report 2 cases, 1 of lung carcinoma and the other of hepatoma, in which the patients had radiographic and endoscopic changes compatible with achalasia. However, the onset of symptoms was abrupt and the patients were elderly; these are unusual features for primary achalasia. There have been several other reports of nongastrointestinal neoplasms producing a clinical and radiographic picture similar to achalasia. Although there are several theories as to the cause, our cases would support the concept that direct tumor involvement of the gastroesophageal junction is not necessary to produce significant esophageal dysmotility.

Digital gastrointestinal imaging: the effect of pixel size on detection of subtle mucosal abnormalities.

Five radiographs of double-contrast colon examinations demonstrating subtle mucosal changes of inflammatory bowel disease and five radiographs of healthy colonic mucosa were selected and digitized to four levels of resolution. Pixel sizes of 0.1 mm, 0.2 mm, 0.4 mm, and 0.8 mm were used. Ten radiologists interpreted the images, which were displayed on laser-printed film. Analysis of variance with repeated measures was performed and receiver operator characteristic curves were determined. The results demonstrate that the sensitivity in detecting subtle mucosal abnormalities improved as the resolution improved, with the best sensitivity at the highest resolution; more experienced readers detected details well even at the poorer levels of resolution; the resolution necessary for successfully evaluating the colonic mucosa was lower than expected; and given low noise levels, the matrix size used in conventional television fluoroscopy would be adequate for mucosal evaluation.

Dysphagia in patients with gastric cancer and a normal esophagram.

Five patients presented with dysphagia but did not have abnormal esophageal motility or morphology on the esophagram. Each was found to have a malignant gastric tumor which did not appear to involve the gastroesophageal junction, and this was confirmed surgically in 2 cases. In 2 patients, diagnosis was delayed as a result of failure to examine the stomach following a normal esophagram. In the absence of abnormal esophageal motility, changes involving the gastroesophageal junction, or cerebral metastases, it is postulated that the dysphagia represented a nonspecific regional response to functional obstruction of the upper gastrointestinal tract secondary to an infiltrating neoplasm of the stomach. The fact that the esophagram was normal emphasizes the possibility that gastric lesions in patients with dysphagia may be missed when only a routine esophagram is employed. The authors recommend that the stomach be examined when no apparent cause for dysphagia can be discerned above the gastroesophageal junction.

Radiographic abnormalities in eosinophilic esophagitis.

Eosinophilic gastroenteritis is an unusual condition of unknown cause in which there is eosinophilic infiltration of the gastrointestinal tract usually accompanied by a peripheral eosinophilia. Rarely, it can also involve the esophagus. Recently, the authors have encountered 3 cases of eosinophilic infiltration of the esophagus. All patients had a strong history of allergies. Two of our patients have had upper esophageal strictures, as have 2 other previously reported cases. This appears to be the most common manifestation. One patient had polypoid lesions of the esophagus as well as of the rest of the gastrointestinal tract. Motility disturbances may also be present. Although steroid treatment may be beneficial, the esophageal strictures usually require mechanical dilatation to relieve submucosal fibrosis. This entity should be considered in any patient who has an esophageal disorder in the presence of either a strong history of allergy or peripheral eosinophilia.

A reappraisal of upper gastrointestinal response to low-dose glucagon.

Although glucagon is the most commonly used pharmacologic agent for gastrointestinal studies, its exact effects on upper gastrointestinal examinations have not been properly elucidated. A large study by our group did redemonstrate glucagon's significant effect on gastrointestinal motility. However, gastric distention and coating are not improved by glucagon, nor does it have a predictable effect on gastric emptying. Duodenal visualization does appear to be enhanced by the drug. Patient age, weight, and sex are not significant factors in glucagon's response, although they are variables that have an effect on UGI examinations. This article will review physiologic considerations in upper gastrointestinal examinations, with emphasis on glucagon's pharmacodynamics.

Gastric polyps: radiological evaluation and clinical significance.

Gastric polyps were found in 81 out of 4,692 consecutive radiological examinations (1.7%) and 103 out of 2,656 endoscopic examinations (3.9%) over a 19-month period. Polyps were more frequent in older patients and in women. Of 98 pathologically diagnosed lesions, 73 (74%) were hyperplastic and only two (2%) were adenomatous; most others were submucosal. Gastric polyps were rarely associated with carcinoma; only one patient had an area of severe dysplasia or carcinoma in situ, which was removed by polypectomy. The double-contrast technique had a high sensitivity and specificity in diagnosing gastric polyps. The location and number of lesions were relatively good indicators of pathology, but size and radiographic characteristics were not. The authors suggest that although radiology has a role in initial detection and screening, endoscopy should be the method of choice for further evaluation and follow-up. Histological identification is possible only with biopsy, and preferably polypectomy. The infrequent association with malignancy suggests that surgery is unnecessary in most cases.

Angioimmunoblastic lymphadenopathy of the colon with malignant transformation.

Angioimmunoblastic lymphadenopathy (AILD) is a rare disorder characterized by lymphadenopathy, constitutional symptoms, skin rashes, and a variety of hematologic disorders. Its occurrence in the colon is rare. Late in the disease, immunosuppression occurs, and there is an increased risk of malignant transformation. We present a case of AILD of the colon with eventual transformation into malignant lymphoma.