Functional anatomy of the lymphatic drainage system of the upper aerodigestive tract and its role in metastasis of squamous cell carcinoma

BACKGROUND

Although there is a significant understanding of the vascular anatomy of the upper aerodigestive tract (UADT), there is less detailed knowledge of the architecture and drainage patterns of the lymphatic system. Detailed knowledge of the lymphatic system is critical for understanding the role of sentinal node identification in the management of different cancers.

METHODS

We have combined microscopic techniques with in vivo and in vitro lymphographic studies to survey the architecture and drainage patterns of the lymphatic system of the UADT in 850 organ specimens.

RESULTS

These studies show an interaction of superficial and deep lymphatic networks that vary in density but have a constant distribution characterized by predictable patterns of lymph drainage into the regional lymph nodes.

CONCLUSIONS

Detailed knowledge of the lymphatic system of the UADT contributes to a better understanding of the patterns of metastatic spread of carcinomas of the UADT and provides a strong rationale for the practice of sentinel node identification in the management of these tumors.

[Ultrasound transabdominal study of the gastrointestinal tract]

It has been conventionally believed for a long time that echography of the intestines and other hollow organs containing gas could give very little information and would be even impossible at times due to the acoustic noise created by the gas medium in their lumen. Nevertheless, it is high time to elaborate new methodological approaches to diagnostics of these diseases and assessment of efficiency of the conducted therapy due to the wide spread of gastrointestinal tract diseases, complexity of their pathogenesis, insufficient effectiveness of the current methods of treatment, and the inclination to the prolonged recurrent course.

The normal upper gastrointestinal examination in the ferret

Upper gastrointestinal examinations were performed in 11 unsedated ferrets and 4 ferrets sedated with ketamine and diazepam. Each animal received a 8-13 mL/kg body weight dosage of barium liquid (30% weight:volume). Radiographs were made immediately and at 5, 10, 20, 40, 60, 90, 120 and 150 min (mins) after the barium was administered. Gastric emptying began immediately. Mean total gastric emptying was longer in sedated ferrets (130 +/- 40 min versus 75 +/- 54 min); however, this difference was not statistically significant (p = 0.18). Small intestinal transit time was less than 2 h in all ferrets. The barium-filled small bowel was best visualized on the 20- and 40-min radiographs and did not exceed 5-7 mm in width. Flocculation of barium in the small intestine and adherence of barium to the stomach mucosa was seen in almost all animals. The longitudinal colonic mucosal folds in the colon were well visualized in the normal upper gastrointestinal study and aided in distinguishing small intestine from large intestine. The use of ketamine and diazepam sedation did not significantly affect the parameters evaluated in the upper gastrointestinal study series.

[Absorption of L-lysine diatrizoate from the gastrointestinal tract: the influence of surgery, inflammation and neoplasia]

PURPOSE

To ascertain whether the absorption of L-lysine diatrizoate, a sodium-free salt of the contrast-giving diatrizoic acid, from the gastrointestinal tract is increased by surgery, inflammation or neoplasia.

MATERIAL AND METHODS

Using contrast medium containing L-lysine diatrizoate for intestinal opacification, this prospective study compared 32 radiographic examinations of the upper gastrointestinal tract with 52 radiographic examination of the lower gastrointestinal tract. In blood samples taken from the patients immediately after the radiographic examinations, the concentration of diatrizoic acid was determined by high pressure liquid chromatography. The results were correlated with sex, age, surgical history and any evidence of inflammatory or neoplastic diseases.

RESULTS

The serum diatrizoic acid concentration in patients after oral administration was 3.62 (95% CI, 2.86 - 10.17) microg/ml. The titer was lower in patients who had undergone abdominal surgery than in patients without surgery. Serum diatrizoic acid concentration in patients after rectal administration was 0.30 (95% CI, 0.13 - 0.60) microg/ml. The titer was significantly higher (p < 0.05) in patients suffering from inflammatory conditions or neoplasms than in the other patients.

CONCLUSION

The L-lysine salt of diatrizoic acid is absorbed in larger amounts from the upper than from the lower gastrointestinal tract. Absorption is not increased after abdominal surgery. However, inflammatory conditions and neoplasms of the large bowel increase the uptake of contrast medium from the intestine.

Routine upper gastrointestinal Gastrografin swallow after laparoscopic Roux-en-Y gastric bypass

BACKGROUND

Upper gastrointestinal (UGI) swallow radiographs following laparoscopic Roux-en-Y gastric bypass (LRYGBP) may detect an obstruction or an anastomotic leak. The aim of our study was to determine the efficacy of routine imaging following LRYGBP.

METHODS

Radiograph reports were reviewed for 201 consecutive LRYGBP operations between April 1999 and June 2001. UGI swallow used Gastrografin, static films, fluoroscopic video, and a delayed image at 10 minutes. Mean values with one standard deviation were tested for significance (P < 0.05) using the Mann-Whitney U test statistic.

RESULTS

Of 198 available reports, UGI detected jejunal efferent (Roux) limb narrowing (n = 17), partial obstruction (n = 12), anastomotic leak (n = 3), complete bowel obstruction (n = 3), diverticulum (n = 1), hiatal hernia (n = 1), and proximal Roux limb narrowing (n = 1). A normal study was reported in 160 cases (81%). Partial obstruction resolved without intervention. Complete obstruction required re-operation. Compared to 6 patients who developed delayed leaks, early identification of a leak by routine UGI swallow resulted in a shorter hospital stay (mean 7.7 +/- 1.5 days vs 40.2 +/- 12.3 days, P < 0.03).

CONCLUSIONS

Early intervention after UGI swallow may lessen morbidity. Routine UGI swallow following LRYGBP does not obviate the importance of close clinical follow-up.

Sensitivity and specificity of postoperative upper GI series following gastric bypass

BACKGROUND

Routine postoperative GI series has been common before discharging gastric bypass patients. 78,000 operations were performed in the USA in 2002. At 75 dollars each, the total annual expenditure for the upper GI series approaches 6 million dollars. This study examines the value of performing routine upper GI series.

MATERIALS AND METHODS

From 1996 to 2000, 396 open gastric bypass procedures were performed by one surgeon at the University Medical Center. 242 randomly selected charts were retrospectively reviewed for signs and symptoms possibly related to leak or obstruction. Radiology reports were compared with clinical findings.

RESULTS

82% of patients (192/242) were discharged following unremarkable postoperative courses and normal x-rays. 18% (44/242) exhibited one or more clinical signs suspicious of leak or obstruction. These included fever, tachycardia, tachypnea, inordinate pain, elevated white cell count or GI hemorrhage. Leak was reported in 5, and obstruction in 5. 4 patients with reported leaks were re-operated: 2 were positive for unconfined leak requiring surgical treatment; 2 had negative laparotomies. The 2 patients (0.82%) with free leakage had dramatic clinical deterioration, and x-rays were confirmatory rather than diagnostic. 1 patient with a minimal confined leak was treated non-operatively. 8 films were misread as showing a leak when none was present: 2 underwent negative laparotomy, the others being correctly interpreted after review. 8 of 10 initial interpretations were falsely positive.

CONCLUSION

Routine postoperative GI series following gastric bypass is not beneficial. All true leaks are demonstrated when x-rays are indicated. We recommend GI series only when clinically indicated. GI series had low positive predictive value for leak.

The "wandering needle"

Suspected aspiration of a radiopaque foreign body can easily be confirmed by a chest film. We report a case of a boy with chest-film confirmed aspiration of a needle into his right main bronchus, in whom no needle was found during bronchoscopy. In retrospect, the boy had expectorated the needle without noticing it in the interval between making the diagnosis and the actual bronchoscopy. We propose to reconfirm aspiration of a radiopaque foreign body by fluoroscopy shortly before commencing bronchoscopy.

Pediatric "body packing"

BACKGROUND

Recent events in the United States have led to increased security at national borders, resulting in an unexpected increase in drug seizures. In response, drug smugglers may begin using children as couriers, including using them as "body packers."

OBJECTIVE

To look at the occurrence of body packing, the concealing of contraband within the human body, which is well documented in adults, in the pediatric literature.

PATIENT REPORTS

Two cases of pediatric body packing, in boys aged 16 years and 12 years. Patient 1, a 16-year-old boy, presented with findings consistent with opioid intoxication after arriving in the United States on a transcontinental flight. His mental status improved after he received naloxone hydrochloride, and he subsequently confessed to body packing heroin. He was treated with a naloxone infusion and aggressive gastrointestinal decontamination. He ultimately passed 53 packets of heroin, one of which had ruptured. He recovered uneventfully. Patient 2, a 12-year-old boy, presented to the emergency department with rectal bleeding. He had recently arrived in the United States from Europe, and he confessed to body packing heroin. He was treated with whole-bowel irrigation and activated charcoal, and he subsequently passed 84 packets. He also recovered uneventfully.

CONCLUSIONS

We report the first 2 cases of body packing in the pediatric literature and review the diagnosis and management of this clinical entity. Pediatricians should be aware that body packing, regrettably, is not confined to the adult population.

Radiography and image-intensified fluoroscopy of barium passage through the gastrointestinal tract in six healthy Amazon parrots (Amazona aestiva)

Gastrointestinal contrast studies were performed in six clinically healthy blue-fronted Amazon parrots (Amazona aestiva) using radiography and image-intensified fluoroscopy. During examination, the birds were confined in a perspex cage. The quality of the lateral radiographs was adequate for assessment of the contrast medium-filled gastrointestinal tract. Thirty minutes after administration of 20 mL/kg of a 25% barium sulphate suspension directly in the crop, in all birds the ventriculus was totally outlined by barium. After 60 min, the small intestine was filled in five of six birds. After 180 min, the crop was empty in all birds. The barium-outlined ventriculus had differences in shape on radiographs of individual birds and also between birds. The colon and cloaca had further filling after 120 to 300 min. With image-intensified fluoroscopy, gastrointestinal motility was evaluated. Contractions of the crop were seen, and boluses of contrast medium passing through the esophagus toward the proventriculus were easily identified. Proventricular contractions were rarely noted, but ventriculus motility was present and clearly defined. The ventriculus had a mean of 3.7 contraction cycles/min. In the duodenum and small intestine, rapid antegrade and retrograde peristaltic movements in combination with segmental contractions were seen. In the colon, occasionally very slow peristaltic activity, mainly of segmental nature, was present. During the examinations, no defeacation was recorded. Confinement in a small perspex cage provides an adequate and handy radiological set-up for evaluation of gastrointestinal passage and motility in birds, minimizing the influences of stress and anesthesia.

Gender differences in gut transit shown with a newly developed radiological procedure

BACKGROUND

Gut transit measurements are essential for understanding the pathophysiology of many gastrointestinal disorders. The ideal bowel transit test should be easy to perform, widely accessible, reproducible, non-invasive and inexpensive and the risks should be minimal. These requirements prompted us to develop a procedure for simultaneous measurement of gastric emptying, small-bowel transit and colonic transit at one visit. We assessed the influence of gender, body mass index, age, menopause and smoking on gastrointestinal transit in healthy subjects.

METHODS

Eighty-three healthy subjects (43 women) were included. Colonic transit was based on 10 radiopaque rings given daily for 6 days with fluoroscopy on day 7. Then, the subjects had a test meal containing 20 radiopaque markers. Using fluoroscopy, gastric emptying and small-bowel transit of the markers were followed until they reached the colon.

RESULTS

Gastric emptying, small-bowel transit and colonic transit were significantly slower in female healthy subjects compared to males (2.9 (1.6-4.9) h, median and percentile 10-90, versus 2.4 (0.7-3.7) h, P=0.005; 4.4 (2.1-11.1) h versus 3.2 (1.5-6.0) h, P=0.001; 1.5 (1.0-3.7) days versus 1.3 (0.8-1.9) days P=0.002), respectively. Small-bowel transit was significantly faster in women with overweight and in postmenopausal women compared to lean and premenopausal women, respectively.

CONCLUSION

This procedure meets most of the requirements of the ideal bowel transit test and is easily performed at one visit. Small-bowel transit as well as gastric emptying and colonic transit were significantly slower for women.

Abdominal leiomyosarcomas: radiologic appearances at various locations

Leiomyosarcomas are soft tissue tumors that account for approximately 15% of all soft tissue sarcomas. Leiomyosarcomas may be located at almost any part of the abdomen but especially are more common in the retroperitoneum, followed by gastrointestinal tract and genital system. They develop mainly in adult life and are very rare in children. In this article, imaging findings of leiomyosarcomas in various abdominal locations are presented. Radiologic studies are capable of providing useful information on the localization, size, changes in the internal structure of the tumor, its extension and invasion. Leiomyosarcoma should be considered in the differential diagnosis in case of detection of a large, circumscribed, and heterogenous abdominal mass. Histopathologically, diagnosis of malignancy depends particularly on mitotic counts, size, rate of necrosis, and infiltrating margins.

Sonographic investigations of the gastrointestinal tract of granivorous birds

This article describes the sonographic examination of the normal gastrointestinal tract of granivorous birds. Preliminary tests with dead birds were performed to get an idea of the sonographic echotexture of the avian gastrointestinal tract. Later, clinically healthy seedeaters of different weights were examined sonographically. As equipment a convex microcurved scanner with a particularly small coupling surface and an adjustable frequency from 5.5-7.5 MHz was used. For the investigation of the gastrointestinal tract, six sonographic approaches are described. After a starving time of 18 hours in the granivorous birds and water input, the best sonographic image quality could be obtained. Using this method, the crop, ventriculus, intestines, and cloaca could be demonstrated sonographically; whereas, it was not possible to visualize the normal proventriculus in granivorous birds. In contrast to mammals, the different layers of the wall of the gastrointestinal tract could not be visualized with the equipment used. Motility of individual parts of the gastrointestinal tract (GI tract), however, could be well demonstrated.

Intravenous glucagon: does it optimize evaluation of the gastrointestinal tract on helical CT?

Forty outpatients were randomized into two groups of 20. Twenty patients received 1 mg of intravenous glucagon and the other 20 did not. Three radiologists evaluated the bowel using a qualitative score and mean scores for each bowel level were compared. A different radiologist measured the maximal diameter of bowel at seven levels. There were no significant differences in qualitative or quantitative data for the two groups. Intravenous glucagon is therefore not routinely recommended for helical CT of the abdomen.

Performance characteristics of scintigraphic transit measurements for studies of experimental therapies

BACKGROUND

The intra- and inter-individual reproducibility of gastrointestinal and colonic transit tests require full characterization.

AIMS

(i) To characterize the normal values and reproducibility effects of age and gender on the scintigraphic transit of solids in health. (ii) To compare scintigraphic and radio-opaque marker measurements of colonic transit. (iii) To estimate demonstrable effect sizes for different transit end-points based on observed variations.

METHODS

A scintigraphic gastrointestinal and colonic transit study and the mean colonic transit time were measured using radio-opaque markers in 37 healthy volunteers; 21 subjects had a repeat scintigraphic test 3 weeks later.

RESULTS

Gastric emptying at 4 h was highly reproducible (coefficient of variation, 4%) on repeat testing. The colonic measurement varied by more than 1 geometric centre unit in 37% of subjects at 24 h and in 26% of subjects at 48 h. There were no age- or gender-related differences in transit. Effect sizes demonstrable with 14 subjects per group were in the range previously shown to be clinically relevant: 25% change in gastric emptying at 4 h; 1.5 geometric centre unit change in colonic transit at 48 h.

CONCLUSIONS

These data demonstrate the reproducibility and performance to be expected of transit measurements and are essential for designing studies in experimental therapeutics.

Colonic delivery of 4-aminosalicylic acid using amylose-ethylcellulose-coated hydroxypropylmethylcellulose capsules

BACKGROUND

4-Aminosalicylic acid has the potential for use in the treatment of diseases of the colon.

AIM

To assess the feasibility of delivering 4-aminosalicylic acid directly to the colon using a hydroxypropylmethylcellulose capsule coated with a mixture of amylose, a polysaccharide metabolized by bacterial enzymes in the colon, and ethylcellulose.

METHODS

Seven healthy male volunteers received, on three separate occasions, an uncoated or amylose-ethylcellulose-coated hydroxypropylmethylcellulose capsule containing 4-aminosalicylic acid Na (550 mg), or an intravenous injection of 4-aminosalicylic acid Na (135 mg). The capsules were radiolabelled with 99mTc to allow their positions in the gastrointestinal tract to be followed using a gamma camera. Plasma and urine samples were collected and assayed for 4-aminosalicylic acid and metabolite concentrations.

RESULTS

The uncoated capsules broke down within 10 min in the stomach, allowing rapid and complete absorption of the drug. The coated capsules remained intact in the upper gastrointestinal tract, and had a median gastric emptying time of 61 min (interquartile range, 77 min) and a median colon arrival time of 363 min (interquartile range, 185 min). For the coated capsules, only the metabolite was detected in the plasma and/or urine after the capsules had reached the colon.

CONCLUSIONS

The specific coating protected the drug until the capsule reached the colon, where 4-aminosalicylic acid was slowly released and absorbed. Thus, such a formulation has the potential for use in the treatment of inflammatory bowel disease.

[The investigation of bioadhesive property of carbomer 934 by gamma camera in vivo]

To study bioadhesive property of carbomer 934 in dog alimentary tract, carbomer 934 and ethylcellulose were radiolabelled with technetium-99 m. The gastrointestinal emptying rate of these materials was measured by the technique of gamma scintiscan. The results showed that the empty rate of adhesive material (carbomer 934) was remarkably slower in dog alimentary tract compared to nonadhesive material (ethylcellulose). It is concluded that, in dog, the interaction between gastrointestinal mucus layer and adhesive material or nonadhesive material was significantly different. Carbomer 934 had stronger bioadhesive property in vivo than that of ethylcellulose.

Application of the Doppler ultrasound examination in digestive tract arterial pathology

Doppler ultrasonography represents a noninvasive method of examination of the peripheral vessels which has been known for a long time. The application of the technique in splanchnic vascularization provides information regarding the vessels permeability, collateral circulation (in case of total obstruction), hemodynamic alterations in normal and pathological conditions. Though the results reported in literature regarding the method are contradictory, the use of Doppler ultrasound for the assessment of splanchnic circulation is encouraging and the technique may represent a method of patient selection for invasive examinations.

Early gastrointestinal function and nutritional status in preterm infants with cystic periventricular leukomalacia

OBJECTIVE

To retrospectively investigate the early gastrointestinal function and the nutritional status of very low birth weight (VLBW) infants with cystic periventricular leukomalacia (PVL).

METHODS

Sixty-five VLBW infants who were admitted to Kakogawa Municipal Hospital were divided into 2 groups: 5 infants were in the PVL group, and the remaining 60 infants were in the normal group. The gastrointestinal function of the infants in the early neonatal period was compared between the 2 groups using an analysis of gastric aspirates and abdominal radiographs, and pulsed-Doppler ultrasonographic measurement of the flow velocity in the superior mesenteric artery (SMA).

RESULTS

In the first week, there were more days in which abdominal gastric residual fluids occurred in the PVL group than in the normal group. The occurrence of abnormal findings in the abdominal radiograph within the first 7 days was significantly higher in the PVL group than in the normal group. Longitudinal ultrasonographic comparisons of the SMA flow velocity showed that the mean values in peak systolic velocity and in time-averaged velocity were both significantly higher in the PVL group than in the normal group before 7 days of life. Both the total volume of milk ingested and the total energy intake in the PVL group were significantly lower than in the normal group within the first 2 weeks of life.

CONCLUSIONS

Despite the low number of infants with PVL, we may suggest that the gastrointestinal function of the preterm infants with cystic PVL may deteriorate significantly compared to normal infants in the early neonatal period of life, and consequently, the early nutritional intakes in the PVL infants are inferior to those in the normal infants.