Spontaneous biliary-enteric fistulas; some considerations on the management of gallstones.

During the past ten years a diagnosis of biliary-enteric fistula was made in thirty-five patients. Six were entirely asymptomatic and another seven patients had suffered only mild symptoms for a short period of time. This indicates that the gallbladder can undergo recurrent episodes of inflammation to the point of fistula formation, with little or no clinical signs of symptoms. An aggressive surgical approach is therefore warranted in patients with cholelithiasis, even when silent stones are involved.

Ureteral changes in polyarteritis nodosa as seen during excretory urography.

The conventional excretory urogram may provide valuable information in the diagnosis of polyarteritis nodosa. A finding of imprints on the ureteral wall or a nodular appearance of the ureter simulating a string of pearls would seem to be pathognomonic for this disorder. Two cases with these manifestations are presented and the differential diagnosis is discussed.

The radiological approach to leiomyoma of the oesophagus with a long-term follow-up.

Long-term follow-up of leiomyomas in the oesophagus is discussed from the radiological point of view. It is the authors' impression that surgical intervention is not a matter of urgency in the treatment of these tumours as their tendency to undergo malignant change is very rare. Nine cases of leiomyoma of the oesophagus were followed for periods ranging from 1 to 15 years. None showed malignant degeneration.

Long-term intravesical thiotepa treatment in patients with superficial bladder tumors and vesicoureteral reflux.

We studied the incidence of myelosuppression and renal function in 33 patients treated by repeated resections of bladder tumors and thiotepa instillations for at least 26 months in the presence of vesicoureteral reflux. Of the 33 patients 28 had unilateral and 5 had bilateral reflux. Transient myelosuppression occurred in 5 patients (15.1 per cent), including 2 with bilateral reflux. Renal function remained stable in all but 2 patients who had decreased renal function when thiotepa was started. Our experience has shown that long-term thiotepa instillation in the presence of vesicoureteral reflux is relatively safe, with no significantly increased incidence of myelosuppression and no detrimental effect on renal function.

Fused epiploic appendages simulating carcinoma of the left colon.

A 60-year old male with a history of rectal bleeding was operated upon because of the finding of a filling defect on barium enema examination. At operation it was found that the defect was produced by the fusion of two epiploic appendages. Following release of the adhesion the colon regained its normal appearance and postoperative barium enema showed no pathological findings.

Prolonged cimetidine therapy in ulcerated Barrett's columnar-lined esophagus.

In a 77-year-old man with dysphagia, x-rays demonstrated an irregular stenotic process in the lower third of the esophagus, suggesting malignancy. Endoscopy disclosed moderate narrowing of the lumen and several ulcers separated by bulges. Serial biopsies revealed Barrett's mucosa. Cimetidine 1 g/day led to prompt improvement and endoscopically there was a disappearance of the lesions after 3 months of therapy. Reduction of the drug to 400 mg/day 3 months later with supplements of antacids and metoclopramide was followed by reappearance of symptoms and recurrence of a deep ulcer. Raising the dose of cimetidine to 1 g/day again resulted in healing and since then a maintenance dose of 600 mg cimetidine with antacids and metoclopramide has been successful in preventing recurrence. This long-term study in a patient with Barrett's esophagus showed 1) that cimetidine can be effective in treating such patients; 2) the prophylactic value of multitherapy as a maintenance regimen, and 3) the importance of careful follow-up.

Upper tract tumours in patients with vesico-ureteral reflux and recurrent bladder tumours.

27 patients with recurrent low-grade, low-stage transitional cell carcinoma (TCC) of the bladder and uni- or bilateral vesico-ureteral reflux were followed for up to 18 years in order to study a possible higher incidence of TCC of the upper tract. None of the patients developed tumours of the upper collecting system during the follow-up period. Routine bladder instillations with Thiotepa may be one explanation of such a finding.

Comparison of the sensitivity of 99mTc-methyl diphosphonate bone scan with the skeletal X-ray survey in multiple myeloma.

In the diagnosis of multiple myeloma (MM), the radiological skeletal survey (RSS) was proven to be most useful for the detection of bone lesions. Since 1961, a new technique radioisotopic bone scan (RIBS), for the detection of such lesions, using 85Sr and 99mTc, has been shown to be highly sensitive for the detection of skeletal metastases of epithelial tumors. We have studied 30 patients with plasma cell dyscrasia (PCD) by both methods and concluded that RSS is clearly superior to RIBS in PCD. As RIBS detected less than 50% of the lesions demonstrated by RSS there seems to be no indication for a routine RIBS in the initial work-up of patients suspected to have PCD. However, due to the fact that RIBS is useful for the detection of new bone formation it has a certain value in the localization of pathological fractures in MM, mainly in vertebral compression.

Unanticipated vesicoureteral reflux: a possible sequela of long-term thio-tepa instillations to the bladder.

Vesicoureteral reflux was studied by retrograde cystograms in 75 patients with recurrent transitional cell carcinoma of the bladder. Unilateral reflux was detected in 6 of the 14 patients (42.8 per cent) treated by transurethral resection of the bladder tumors. Five of these cases of reflux were anticipated and 1 was unanticipated. Among 61 patients treated by tumor resection and adjuvant instillations of thio-tepa reflux was found in 33 ureters of 25 patients (41.0 per cent). Of the 33 cases of reflux 15 were anticipated, while 18 were unanticipated. All the anticipated cases of reflux resulted from the direct effect of tumor resection on the ureteral orifice. The effect of thio-tepa on bladder mucosa and the ureteral orifices is suggested as a possible cause of the unanticipated cases of reflux.

New therapeutic approach in postoperative phytobezoars.

Postoperative phytobezoars (duration from 2 months to 46 years) after surgery for duodenal ulcer disappeared in seven patients, by both x-ray and gastroscopy, on conservative approach aimed at the major role of delayed gastric emptying in phytobezoar formation. During a 3-day period, metoclopramide was given by drip infusion, 40 mg/24 hours, and the patient received only a copious clear diet, with no solid food. In one patient, two courses of treatment were necessary for complete elimination of the phytobezoar. None of the patients had any underlying disease. All but one had good dentition. "Disruption" of the bezoars allowed the discovery upon endoscopy of unusual etiological features such as carcinoma of the stoma and stomal polypoid hypertrophic gastritis (so-called gastritis cystica polyposa ) in one patient, and a retained suture narrowing the stoma in another.