Computed tomography findings of internal hernia after gastric bypass that may precede small bowel obstruction.

PURPOSE: This study evaluates computed tomography signs of internal hernia in gastric bypass patients, including several previously unreported signs suggestive of internal hernia. METHODS: Eighteen patients with surgically proven internal hernia were included in the study cohort. The signs analyzed included the mesenteric swirl, hurricane eye, mushroom sign, and dilated small bowel loops, as well as previously non-investigated signs such as bowel wall edema, engorged mesenteric vessels, engorged mesenteric lymph nodes, and hazy mesenteric fat. We also separately examined internal hernia patients without overt small bowel obstruction (SBO), since these are the patients most likely to get overlooked by radiologists. RESULTS: The most prevalent sign in all internal hernia patients was mesenteric vessel engorgement, seen in approximately 79-84 % of patients overall and 73-75 % of patients without overt SBO. The level of agreement between our two readers for the eight total signs reviewed was all moderate to substantial (using Cohen kappa values), reflecting their reliability as markers of internal hernia. The highest level of agreement was seen in vessel engorgement at 0.91, followed by three other signs [hurricane eye, SBO, bowel edema] with levels of agreement at 0.86. CONCLUSIONS: We conclude that more subtle signs of internal hernia should be included in radiologist search patterns for patients with internal hernia, especially those presenting multiple times for abdominal pain, as these may reflect surgically correctable intermittent herniations.

Visceral fat and race-dependent health risks in obese nondiabetic premenopausal women.

Our previous finding that a waist-to-hip ratio (WHR) >0.85 was not associated with similar health risks in black, compared with white, obese premenopausal non-diabetic women of similar fatness is attributed to either 1) a different relationship between WHR and visceral adiposity or 2) differences in the relationship between visceral adiposity and the metabolic abnormalities of obesity. We measured visceral (VAT) and subcutaneous adipose tissue (SCAT) areas at midwaist in 25 black and 25 white obese nondiabetic pre-menopausal women with similar BMI, percentage body fat, and wide range of WHR (0.7-0.95 for black women and 0.7-0.9 for white women) and then compared insulin sensitivity index (SI), glucose and insulin areas under the 2-h curve (AUCs) during an oral glucose tolerance test (OGTT), and blood lipids in the two groups before and after adjustments for total body and visceral adiposity. After adjusting for total body fat mass (FM), obese black women had significantly less VAT (by 32 cm2) and lower VAT/SCAT for any given WHR. The regression equations predicting the SI the glucose and insulin AUCs, and the triglyceride and HDL cholesterol levels from regional adipose tissue measurements (VAT, SCAT, or VAT/SCAT) and from total body fat (FM or percentage body fat) had slopes that were not significantly different for black and white women. LDL cholesterol levels were independently related to VAT in black but not in white women. The black women had a similar SI insulin AUC, and triglyceride levels but significantly lower glucose AUC and higher HDL cholesterol levels (P < 0.001), after adjusting for VAT and FM. Regression analysis of the pooled data showed that high VAT and high VAT/SCAT, but not SCAT, predicted lower SI higher glucose and insulin AUCs during OGTT, and higher triglyceride levels, independent of total adiposity. We conclude that while increases in VAT and VAT/SCAT adversely affect metabolism in both black and white obese premenopausal women, similar levels of total body and visceral adiposity are associated with different metabolic risk factors in these groups.

Use of magnetic resonance urography.

OBJECTIVES: Magnetic resonance urography (MRU) is a new technique that uses heavily weighted T2 coronal images with fat suppression pulse. Urine appears white on MRU, resembling an intravenous urogram (IVU). Contrast agents are not necessary. This study describes the use of MRU in the diagnosis and treatment of patients with hematuria. METHODS: One hundred six patients with microscopic or gross hematuria and 6 normal volunteers underwent MRU between 1992 and 1995. A modified, heavily weighted T2 technique with intravenous administration of furosemide and ureteral compression was used. Thirty-two patients had other imaging techniques as well for comparison. RESULTS: MRU provided high-resolution images in almost all cases; 73 (69%) had a normal MRU. Significant findings in the 33 patients with abnormalities included renal cysts in 17 (51%), renal cell carcinoma in 6 (18%), transitional cell carcinoma in 5 (15%), ureteropelvic junction obstruction in 3 (9%), and stones causing obstruction in 6 (18%). Five patients with renal failure also had good visualization of the entire urinary tract. MRU was comparable to other imaging modalities except in identifying nonobstructing calculi. CONCLUSIONS: MRU provides an alternative to conventional imaging of the urinary tract, especially in those patients who have contraindications to ionizing radiation and contrast agents. Improvements in resolution, technique, and cost have to be addressed before it can be used regularly in urologic practice.

Role of CT in evaluating patients with small-bowel obstruction.

The accurate and rapid diagnosis of acute small-bowel obstruction has troubled surgeons and radiologists for more than a century. With the advent of CT, solving the problem is now a possibility. CT can accurately diagnose obstruction, determine the likely cause and location, and even suggest whether there is associated bowel ischemia or strangulation.

The How Are You? scale: a quality-of-life outcomes measure for routine practice.

The How Are You? scale, a quality-of-life outcomes self-report measure to be completed by patients, was developed to address the concerns of the mental health consumer movement. Specific concerns included using less technical language in assessing mental health problems and developing a collaborative dialogue between clinician and patient. The How Are You? scale is a user-friendly instrument that allows patients to be actively involved in their assessment and treatment process. To implement the How Are You? scale into a recording and measurement system, its psychometric properties were assessed using two samples: (1) An employee group from The Menninger Clinic was used to assess internal consistency and stability, and (2) a patient group from The Menninger Clinic was used to assess known-group and discriminant validity, as well as sensitivity to change. The How Are You? scale was found to have good internal consistency and stability and good known-group and discriminant validity. It was also found to be sensitive to change. Although data continue to be collected at The Menninger Clinic, initial indications are that the How Are You? scale is a psychometrically sound outcomes measurement tool.

Which treatments help? The patient's perspective.

In an effort to determine which specific aspects of treatment might account for patient satisfaction, the authors developed the Components of Treatment Questionnaire. This measure, which was administered to 500 adult inpatients along with the Client Satisfaction Questionnaire (CSQ-8; Larsen, Attkisson, Hargreaves, and Nguyen, 1979), asked patients to assess the helpfulness of their treatment. Convinced that patient input is pertinent to program design, the authors later surveyed 46 patients on treatments that they perceived as helpful and would like to receive. Respondents identified individual relationships and problem-focused therapies as the most helpful aspects of treatment.

Subacute osteoporotic compression fracture: misleading magnetic resonance appearance.

Three patients with benign subacute osteoporotic vertebral compression fractures are presented. T1 weighted magnetic resonance (MR) images (SE 500/30) showed decreased vertebral signal. Because the results of the MR examination were thought to indicate malignant disease, extensive medical workups, including one biopsy, were pursued in all three patients. Routine (SE 500/30) spin-echo pulse sequences cannot definitively distinguish between benign and malignant vertebral compression fractures.

Volvulus of the transverse colon.

A volvulus of the transverse colon in a 78-year-old woman is reported. The diagnosis is established by abdominal film and barium enema with surgical confirmation. Women are more commonly affected than men. There is a higher mortality rate for volvulus of the transverse colon than for either sigmoid or cecal volvulus.

Abdominal CT findings when the superior vena cava, brachiocephalic vein, or subclavian vein is obstructed.

OBJECTIVE: We evaluated findings on contrast-enhanced abdominal CT scans that suggest obstruction of the superior vena cava, brachiocephalic vein, or subclavian vein. SUBJECTS AND METHODS: We conducted a retrospective review of 22 patients with superior vena caval, brachiocephalic vein, or subclavian vein obstruction and analyzed the upper abdominal images on a chest CT scan or an abdominal CT scan. We assessed collateral vessels in the upper abdomen to answer the following question: Did enhancement approach undiluted IV contrast or were there other findings? In the second part of our study, we conducted a prospective review of abdominal CT scans of 200 patients without known mediastinal disease or known upper extremity venous occlusion to determine the frequency of abnormal enhancement of these vessels in a healthy population. RESULTS: The groups of collateral vessels revealed on abdominal CT scans were azygos or hemiazygos veins, internal mammary veins, lateral thoracic and superficial thoracoabdominal veins, vertebral venous plexus veins, and small mediastinal collateral veins. In the retrospective series, one patient had focal enhancement of the liver and early inferior vena caval enhancement due to collateral vessels. In the prospective series, abdominal CT scans of two patients (1%) revealed dense undiluted enhancement of one or more groups of collateral vessels: One patient had an ipsilateral pacemaker, and the other patient had an anterior neck phlegmon to the upper mediastinum. Both conditions may have been factors in the revealing of the collateral vessels. Two other patients (1%) in the prospective series had mild to moderate vessel enhancement that was less than that from undiluted contrast material. In one of these patients, the enhancement was related to abdominal wall hyperemia after surgery. In the other patient, enhancement may have been the result of ipsilateral axillary nodes. CONCLUSION: On upper abdominal CT scans, dense undiluted contrast material in the collateral vessel groups that we studied suggests possible obstruction of the superior vena cava, brachiocephalic vein, or subclavian vein.

Feasibility of double-contrast barium enema in the elderly.

In order to evaluate the feasibility of performing double-contrast barium enemas in the elderly, a consecutive series of 310 patients above 60 years of age referred for barium enema examinations was analyzed relative to the rate of successful studies. There was an overall success rate of 94.8%. There was a 99% success rate in patients in the seventh decade, 94.9% in the eighth decade, and a 90% success rate in patients 80 years and over. A conclusion is reached that the double-contrast barium enema examination is feasible in the elderly.

Radiologic demonstration of important gastrostomy tube complications.

Complications of gastrostomy tubes have been reported principally in the surgical literature and primarily affecting infants and children. Recent reports in the radiologic literature draw attention to the role of the radiologist in the evaluation of these complications.

Computed tomography in Crohn disease.

Twelve patients with Crohn disease were studied by computed tomography. Characteristic findings of small intestinal involvement include symmetrical bowel wall thickening, a "double halo" appearance on cross section of the diseased bowel segment, and an associated mesenteric fat mass. Computed tomography provided crucial diagnostic information in the management of some of the intestinal and extraintestinal complications of the disease.

Idiopathic esophageal ulceration in the acquired immunodeficiency syndrome: radiologic reappraisal in 10 patients.

Idiopathic esophageal ulceration in patients with AIDS has previously been described. Establishing this diagnosis is important because of the excellent response of these ulcers to corticosteroid therapy. We studied 10 such patients with esophagography and endoscopy. HIV was isolated from the ulcer base in six of the 10 patients utilizing various techniques including in situ hybridization. No other organisms were found. All of the ulcers were in the distal half of the esophagus and were solitary in eight of the 10 patients. The solitary ulcers were large (2.5 x 2.0 cm to 12 x 9 cm) and deep (> 0.5 cm) with undermined margins. In three patients, fistulae arose from the distal esophagus and crossed the gastroesophageal junction. In one patient, a huge idiopathic ulcer perforated into the mediastinum. These latter findings are not seen in the more common ulcerating AIDS esophagitides due to herpes simplex and cytomegalovirus.

An unusual case of diverticulitis complicating pregnancy at 33 weeks' gestation.

A 38-year-old para 2 presented with the gradual onset of nausea vomiting and increasing left lower quadrant pain, at 33 weeks' gestation. She was known to have uterine leiomyomas, with ultrasonography depicting an 8-cm intramural fundal leiomyoma. In addition a left lateral nondiscrete 10 x 8-cm mass was depicted at the point of maximum tenderness. Magnetic resonance imaging (MRI) demonstrated diverticulosis of the descending and sigmoid colon. The patient remained afebrile and received repeated doses of intramuscular analgesics and was cleared by the surgical consultant, only to be readmitted with similar symptomatology 24 hours later. Subsequently, following repeat discharge she delivered at 34 weeks' gestation, and developed a small bowel obstruction during the immediate postpartum course. With the continued finding of a left lower abdominal mass and computed tomography findings suggestive of perforated sigmoid diverticulitis and resulting small bowel obstruction, laparotomy was performed. Multiple adhesions and phlegmon sequelae of chronic perforation of the sigmoid were confirmed, and a diverting descending colostomy and Hartman's procedure were performed. We present unusual MRI findings of diverticulitis in the third-trimester and review the literature pertaining to this unusual complication of pregnancy.

Experience with breast biopsies using the Advanced Breast Biopsy Instrumentation system.

OBJECTIVE: A retrospective review of our experience with advanced breast biopsy instrumentation (ABBI) was undertaken to evaluate its efficacy for excisional breast biopsy of lesions detected on mammography. To our knowledge, experience with ABBI has not been previously reported in the radiology literature. MATERIALS AND METHODS: Biopsies using the ABBI system and an adapted dedicated table were performed in 53 patients who had 54 mammographically evident lesions. Samples were obtained with cannulas ranging in size between 5 and 20 mm. Indications for biopsy were calcifications (n = 22) and masses (n = 31). RESULTS: Forty-five specimens (44 patients) had benign results at pathology: 15 specimens were diagnosed as fibroadenoma, 15 as cystic breast disease, and four as reactive lymph nodes; the remaining 11 specimens had benign diagnoses of adenosis, fibrosis, and hyperplasia. The average specimen size was 4.8 cm in greatest longitudinal dimension. One patient had a nondiagnostic biopsy for calcifications later found to be dermal. Seven patients were diagnosed as having breast cancer; in six of these, the tumor involved the margins of the specimen. One patient had marked atypia that required reexcision for the diagnosis of intraductal carcinoma to be made. CONCLUSION: The ABBI procedure is a more invasive and less readily available procedure than core needle biopsy for sampling of benign breast lesions. In seven cases of malignancy diagnosed at breast biopsy, the ABBI technique completely excised only a single lesion. In our experience, the ABBI procedure offered no advantages over core needle biopsy for either benign or malignant lesions.

Problems in the colonoscopic localization of tumors: continued value of the barium enema.

Six patients in whom errors of diagnosis and therapy occurred because of reliance on colonoscopic tumor localization are presented. Three of the patients required a second laparotomy for surgical resection of a tumor that was missed at the first exploration. While endoscopy is regarded as the diagnostic gold standard, there are problems in its use for colonoscopic localization. Reliance on distance measurements may be misleading. Anatomical variants can be confusing. For this reason, a preoperative barium enema for precise delineation and localization of tumors is recommended. When a barium enema is not feasible, such as when a malignant polyp has been removed endoscopically, preoperative endoscopic localization with injection of India ink or intraoperative colonoscopy must be performed.

Prospective evaluation of colonic obstruction with computed tomography.

BACKGROUND: To determine whether computed tomography (CT) can satisfactorily diagnose and evaluate patients with suspected colonic obstruction. METHODS: Seventy-five patients with suspected colonic obstruction were evaluated prospectively by CT and compared with the gold standards of surgery and/or endoscopy in 65 patients, clinical course in nine, and contrast enema (CE) in one. A limited comparison between CT and CE (26) patients was also made in those patients who had both studies. RESULTS: CT successfully diagnosed colonic obstruction in 45 of 47 patients (96% sensitivity). Pseudo-obstruction was correctly diagnosed in 26 of 28 patients (93% specificity). CT correctly localized the point of obstruction in 44 of 47 patients (94%). CE successfully diagnosed obstruction in only 20 of 25 patients (80% sensitivity). CONCLUSION: In this study, CT proved to be a satisfactory modality in evaluating patients with suspected colonic obstruction. CT may in certain circumstances be preferable to the traditional CE in evaluating these patients.