[Endoscopic visualization of BAR (biofragmentable anastomotic ring)]

The authors present information on the use of a modern sutureless anastomotic connection by means of a biofragmentable ring--BAR (Biofragmentable Anastomotic Ring) which was used in patients to restore the continuity of the GIT after resections in the upper portions of the digestive tract. The authors present their initial clinical experience and emphasize the importance of visualization of biofragmentable anastomoses by gastroscopic examination in case of postoperative complications with the possibility of therapeutic provisions, if necessary.

Evaluation of gastrointestinal involvement of Behçet's disease by nuclear medical techniques

To evaluate the value of nuclear medicine procedures in the diagnosis of gastrointestinal involvement of Behcet's disease in asymptomatic patients, Tc-99m human immunoglobulin (HIG) and Tc-99m leucocyte (LC) whole body scintigraphies were performed on 30 patients with major symptoms of the disease. Comparison of the results with other diagnostic techniques showed that Tc-99m HIG whole body scanning can be a useful diagnostic aid before the disease becomes clinically active in the gastrointestinal system.

Roentgenographic study of ethosuximide-induced functional changes in rat gastrointestinal tract and their modulation by Nivalin in a chronic experiment

Ethosuximide, a typical antiabsence drug, causes gastrointestinal complaints in the drug-treated patients. In the present study we investigated in an experimental model the functional disturbances occurring in rat gastrointestinal tract (GIT) after a 100-day chronic administration of ethosuximide. Contrast radiographic study of rat gastrointestinal tract was used. The mechanical activity of GIT smooth muscle (SM) preparations was measured using an in vitro isometric technique. The 100-day ethosuximide treatment induced atonia, disturbed peristalsis, and lead to a delay of the contrast material evacuation from the gastrointestinal tract combined with a reduction of the acetylcholine effect on the contractions of GIT smooth muscles in ethosuximide-treated rats. Nivalin cannot eliminate the ethosuximide-induced disturbances in the gastrointestinal tract after a 100-day administration of ethosuximide to the rats. It is thus assumed that Nivalin is not capable of compensating the inhibiting effect of ethosuximide. The authors assume that desensitization of acetylcholine receptors may occur and this reduces the effect of Nivalin action.

Set-up error & organ motion uncertainty: a review

Conformal radiotherapy allows improvement in the treatment outcome due to increased targeting accuracy through advanced beam shaping techniques to precisely conform radiation dose to the geometry of the tumour. Treatment set-up and organ motion uncertainties are unavoidable factors that are limiting increases in accuracy and have to be accounted for in conformal treatment planning. The magnitudes of set-up errors and organ motion uncertainties for specific sites, and using various set-up techniques, have been quantified in the literature. However, the parameters used with these measurements and the presentation of the data has differed between studies for the same site. The purpose of this paper is to analyse and combine the published material into a uniform format and to display typical reported values of set-up and organ motion uncertainties. Values measured under similar conditions were averaged across studies. The results of this analysis illustrate (1) variability in the parameters used for measurements across studies, (2) typical motion ranges of the prostate, kidneys, liver and diaphragm, (3) typical means and standard deviations for set-up errors associated with the prostate, pelvis, brain, head and neck, thorax, rectum and breast and (4) a brief review of the common methods to lower or account for these uncertainties.

Technetium leukocyte imaging in inflammatory bowel disease

Technetium-99m white blood cell ((99m)Tc-WBC) imaging has been part of the initial evaluation and follow-up of more than 400 children presenting with inflammatory bowel disease (IBD) at Children's Hospital of Pittsburgh. Studies have suggested that (99m)Tc-WBC imaging is superior to contrast radiology in assessing the extent and activity of IBD. With only one examination, (99m)Tc-WBC imaging is ideally suited to obtain a precise temporal snapshot of the distribution and intensity of inflammation, whereas radiography tends to detect more chronic changes. There is a high correlation between (99m)Tc-WBC imaging findings and those of endoscopy. When total colonoscopy cannot be completed satisfactorily or when contrast radiography findings are negative or equivocal, scintigraphy can confirm the presence of ileitis or right-sided colitis. Occasionally, (99m)Tc-WBC imaging is useful in differentiating Crohn's disease from ulcerative colitis. Some studies have suggested that (99m)Tc-WBC imaging is useful as an initial screening modality to exclude IBD. Technetium-99m WBC imaging is noninvasive, practical, safe, requires no bowel preparation, and entails less radiation exposure than contrast radiology or computed tomography.

Abdominal helical CT: milk as a low-attenuation oral contrast agent

One hundred ten consecutive patients were given either whole (4%) milk, 2% milk, water, barium suspension, or no oral contrast agent before abdominal computed tomography (CT). Results with whole milk were superior to those with all other agents for gastrointestinal distention, mural visualization, and pancreas-duodenum discrimination. In bowel loop discrimination, results with 4% milk were equal to those with barium but superior to those with all other agents. Whole (4%) milk is an effective low-attenuation oral contrast agent.

[Non-invasive methods of control of the intestinal motility in surgical practice]

Selective spectral peripheric electrogastroenterography (SSPEGEG), the noninvasive method of the gut functional state estimation, is based on registration of biopotentials from the body surface, generated by stomach and intestine, using apparatus-program unit on the PC IBM base. The possibilities and advantages of this method in comparison with others (roentgenological, radiological, radionuclide, balloonographic and tensiographic) were considered. The principles of the SSPEGEG application for clinical monitoring conduction are adduced.

Carcinoid tumors of the abdomen: CT features

Carcinoid tumors are rare neuroendocrine neoplasms that belong to a more general category of tumor called the APUDomas. Ninety percent of carcinoid tumors are located in the gastrointestinal tract. Abdominal carcinoid tumors are categorized according to the division of the primitive gut from which they arise. Carcinoid tumors originating from the foregut develop in the gastric wall, duodenum, and pancreas; those originating from the midgut develop from the small bowel, appendix, and right colon; and those originating from the hindgut develop from the transverse or left colon or from the rectum. This report illustrates the computed tomographic appearance of primary and metastatic carcinoid tumors of the abdomen. Among the different organs that may be involved by metastases from carcinoid tumor, special emphasis is placed on the liver.

Gastrointestinal imaging: a systems analysis comparing digital and conventional techniques

OBJECTIVE

The purpose of this study was to compare digital and conventional methods of gastrointestinal imaging based on the cost of image storage and estimated overall costs, radiation exposure to the patient, and duration of the examination.

MATERIALS AND METHODS

Our study sample consisted of 128 patients who underwent conventional gastrointestinal studies (64 double-contrast upper gastrointestinal examinations and 64 double-contrast barium enemas) and 139 patients who underwent digital gastrointestinal studies (66 double-contrast upper gastrointestinal examinations and 73 double-contrast barium enemas). The number of images and films for each study was recorded, and the mean cost of image storage and the estimated overall costs for digital versus conventional studies were calculated. Both the duration of fluoroscopy and the time from start to completion of the study were obtained from our radiology information system. From these data, we calculated mean radiation exposure to the patient and the duration of the examination. Finally, referring physicians completed a questionnaire about their level of satisfaction with paper prints generated from digital gastrointestinal studies.

RESULTS

When digital studies were compared with conventional studies, the mean cost of image storage decreased by 45% and the estimated overall 10-year costs decreased by 8%. The mean number of spot images increased by 8% for upper gastrointestinal examinations and by 25% for barium enema examinations, whereas the mean duration of fluoroscopy decreased by 4% and by 10%, respectively. As a result, radiation exposure to patients increased by only 2%, a difference that did not approach statistical significance. Finally, the mean duration of examinations decreased by 24% for upper gastrointestinal examinations and by 33% for barium enemas. Approximately 85% of the physicians who completed the questionnaires indicated that they reviewed the paper prints generated from digital studies and that they would like to continue receiving them.

CONCLUSION

Digital gastrointestinal imaging systems are associated with higher initial costs than conventional systems, but the long-term costs of these digital imaging systems are slightly less because of the lower cost of image storage, and radiation exposure to patients is comparable. The shorter duration of digital examinations is a potential benefit of this technology, allowing improved patient throughput. Finally, referring physicians have a high level of satisfaction with paper prints generated from digital imaging.

Influence of aging on gastrointestinal transit time. An ultrasonographic and radiologic study

RATIONALE AND OBJECTIVES

To assess and compare gastrointestinal (GI) rates in young and aged men under homogeneous conditions of weight and dietetic habits.

METHODS

Gastric emptying time was evaluated by ultrasound. GI transit time was studied radiologically using radiopaque markers.

RESULTS

Final gastric emptying time in elderly subjects was 335 +/- 31 minutes (mean +/- SD) versus 245 +/- 25 minutes in young subjects (P < 0.001). Total GI transit time showed no significant difference between the two groups. Intestinal transit time includes both small bowel and colonic transit; small bowel and colonic transit was not separated in this study.

CONCLUSIONS

Delayed gastric emptying of solid foods could result from progressive autonomic nerve dysfunction occurring with aging. The stomach does not seem to be the segment of the digestive tract that is primarily responsible for the alteration of total GI time.

Postadministration of oral contrast material for abdominal CT in patients with gastrectomy: modified drip ingestion method

We introduce the modified drip ingestion method (MDIM) of administering oral contrast material for abdominal computed tomography (CT) in patients after gastrectomy. MDIM consists of the drip ingestion method, which we have recently reported, with additional ingestion of effervescent agent. MDIM in abdominal CT is a useful technique to improve the degree of distention of the gastrointestinal lumen including anastomotic sites in patients after gastrectomy.

[The diagnosis and preoperative location of digestive endocrine tumors by endoscopic ultrasonography]

Around 30% of the gastroenteropancreatic endocrine tumors (GPET) cannot be preoperatively identified by the common diagnostic imaging techniques. The aim of this retrospective study was to present our experience in the diagnosis and localization of GPET by endoscopic ultrasonography (EUS) performed prior to surgery and compare this with a review of the literature.

PATIENTS AND METHODS

Twenty patients suspected of having specific hormonal syndromes were correlatively explored with US, CT, MR, angiography, octreoscan and radial EUS with Olympus GFUM3/EUM3 and GF-UM20/EUM 20 and 30. Eleven cases were males (55%) and 9 (45%) females with a mean age of 60 years (range: 40-80 years). Of the 20 patients, 14 had endocrine 16 tumors in the pancreas and 6 tumors in the gastrointestinal tract. In 6 patients no tumors were found and were therefore used as a control group. Of the 20 patients, 14 underwent surgery confirming the existence of GPET in 12 cases.

RESULTS

The diagnostic sensitivity and precision of the EUS were of 75 and 78%, respectively, with these percentages being higher to those obtained with other imaging techniques. The specificity was 83%. All these values were slightly lower than the mean obtained on review of the literature. Two pancreatic tumors of less than or equal to 1 cm were detected which had not been previously diagnosed with US, CT and MR. In two cases the exact situation was not determined. Echo-endoscopic exploration of the pancrease could not be completely performed in two cases (10%), one pancreatic carcinoma and one double pancreatic gastrinoma which was gastrectomized. Endoscopic ultrasonography is a good preoperative technique for detecting GPET and in the evaluation of small sized tumors it may surpass other imaging techniques. The usefulness of EUS as a second exploration following US has been suggested for the diagnosis and localization prior to surgery.

Evaluation of esophageal bile reflux after total gastrectomy by gastrointestinal and hepatobiliary dual scintigraphy

Conducting the qualitative evaluation of reconstruction methods is difficult because of their complexity. The aim of the present study was to compare esophageal bile and food reflux by performing gastrointestinal and hepatobiliary dual scintigraphy (GHDS) after various methods of reconstruction following total gastrectomy. Of 17 patients studied, 4 had undergone Roux-en-Y anastomoses (R-Y); 6, jejunal pouch-Y anastomoses (P-Y); and 7, jejunal pouch interposition (P-I). GHDS was performed 1 year after surgery using 111In-diethylene triamine pentaacetic acid administered orally, and 99mTc-pyridoxyl-5-methyl tryptophan administered intravenously. Imaging data from a gamma camera were stored in and processed by a data analyzer. Three patients who had undergone R-Y and one who had undergone P-I complained of heartburn, while one who had undergone R-Y, two who had undergone P-Y, and three who had undergone P-I complained of a feeling of fullness. Esophageal bile reflux was confirmed by GHDS in four of the patients who had undergone R-Y, one who had undergone P-Y, and four who had undergone P-I. Moreover, GHDS demonstrated food retention in two patients who had undergone R-Y, five who had undergone P-Y, and four who had undergone P-I. Weight loss was closely related to the esophageal reflux of bile or food which can be accurately detected by GHDS. Despite the absence of heartburn, patients diagnosed as having bile reflux by GHDS showed poor recovery of body weight.

Ethosuximide inducted changes in the gastro-intestinal tract

Ethosuximide is an alternative medicament that is used for coupling of petit mal, especially in childhood. Some clinical observations show that it has secondary effects on the gastro intestinal tract (GIT). The present research tries to define the characteristics of Ethosuximide--the inducted secondary effects on the GIT, and to explain some of the possible mechanisms that cause them. The changes that occur in the GIT of patients cured with Ethosuximide are registered roentgenologically. The main change is the atony of the stomach and intestines and the reduced peristaltic activity. The influence of Ethosuximide is examined on smooth muscular samples of human stomach, taken in vitro using stomach resection. The medicament authoritatively reduce the spontaneous bioelectrical activity of the smooth muscular tissue, influences mainly it's components that have Ca+ nature. Together with that is indicated relaxation of the smooth muscular samples. In that research is expressed the thesis that this Ethosuximide reduction of the Ca(+)-influx in the smooth muscular cells and the related relaxation probably are one of the main reasons of the secondary effects on the GIT.

[Barium sulfate poisoning?]

We report a case with neurologic symptoms which occurred after iterative radiologic examinations of the gastrointestinal tract with barium sulphate, which were related to a barium encephalopathy. Suspected by the presence of barium in the blood, a systematic intoxication was occurred without any evidence for a gut or a vascular leak. This case raises the question about a possible extraluminal diffusion of such a heavy metal, given orally, in normal conditions of use.

[Hydro-MRT with fast sequences in Crohn's disease: a comparison with fractionated gastrointestinal passage]

PURPOSE

To compare the value of hydro-MRI with that of barium studies in patients with Crohn's disease.

MATERIALS AND METHODS

After an oral bowel opacification using 1000 ml of a 2.5% mannitol solution, axial and coronal breath-hold sequences (T2W HASTE +/- FS, contrast-enhanced T1W FLASH FS) were acquired in 46 patients with Crohn's disease at 1.0 T. The findings of hydro-MRI were compared with those of barium studies.

RESULTS

In the stomach and the small bowel, hydro-MRI and barium studies demonstrated similar numbers of Crohn's involvements (39 vs. 36); in the colon, hydro-MRI showed clearly more affections (23 vs. 10). Hydro-MRI showed 12.7 cm of inflamed bowel per patient, on average (barium studies: 10.4 cm; p = 0.004). There was a good agreement between the two methods regarding the assessment of the extent of Crohn's disease and the severity of bowel stenoses (r = 0.89 and 0.88, respectively).

CONCLUSIONS

For the assessment of Crohn's disease, hydro-MRI is preferable to the barium study because of the superior imaging quality and the lack of radiation exposure.

[The diagnostic and therapeutic strategy in the treatment of foreign bodies of the upper digestive tract: a report of a clinical case and a review of the literature]

The author reports a rare case of foreign bodies ingestion treated surgically. The diagnosis and the type of treatment that must be adopted are defined. The literature is reviewed and the described data compared with the observed case.

Features of Alagille syndrome in 92 patients: frequency and relation to prognosis

We have studied 92 patients with Alagille syndrome (AGS) to determine the frequency of clinical manifestations and to correlate the clinical findings with outcome. Liver biopsy specimens showed paucity of the interlobular ducts in 85% of patients. Cholestasis was seen in 96%, cardiac murmur in 97%, butterfly vertebrae in 51%, posterior embryotoxon in 78%, and characteristic facies in 96% of patients. Renal disease was present in 40% and intracranial bleeding or stroke occurred in 14% of patients. The presence of intracardiac congenital heart disease was the only clinical feature statistically associated with increased mortality (P <.001). Initial measures of hepatic function in infancy including absence of scintiscan excretion were not predictive of risk for transplantation or increased mortality. The hepatic histology of these AGS patients showed a significant increase in the prevalence of bile duct paucity (P =.002) and fibrosis (P <.001) with increasing age. Liver transplantation for hepatic decompensation was necessary in 21% (19 of 92) of patients with 79% survival 1-year posttransplantation. Current mortality is 17% (16 of 92). The factors that contributed significantly to mortality were complex congenital heart disease (15%), intracranial bleeding (25%), and hepatic disease or hepatic transplantation (25%). The 20-year predicted life expectancy is 75% for all patients, 80% for those not requiring liver transplantation, and 60% for those who required liver transplantation.

Evaluation of solid phase radiolabels of dog food for gastric emptying

99mTc-Pertechnetate, 99mTc-mebrofenin, 99mTc-disofenin, 99mTc-sulfur colloid, and 99mTc-Dowex resin beads were evaluated for in vitro stability as a label for both dry extruded, and canned dog food for gastric emptying scintigraphy. A sample of each radiolabeled diet was added to water, gastric juice, intestinal juice, or gastric juice followed by intestinal juice for in vitro digestion. After a 3-hour digestion period, tubes were centrifuged and percentage solid phase retention (%SPR) was calculated. The experiment was repeated three times over a 14-day period to minimize day-to-day variation. For dry dog food, 99mTc-mebrofenin and 99mTc-disofenin had similar %SPR in water (96 and 93%, respectively) and gastric juice (>95% each) and were significantly higher than other labels. For canned dog food, mebrofenin had a 91% SPR for the water or gastric juice digestions, and 99mTc-Dowex had a %SPR of >99%. 99mTc-mebrofenin and 99mTc-Dowex were also tested in vivo, where 99mTc-Dowex had poor stability, and 99mTc-Mebrofenin had excellent stability. 99mTc-Mebrofenin is a suitable label for dog food for gastric emptying scintigraphy.

[Digestive system's large and changing needs of blood supply]

Doppler utrasonography has made it possible to record blood flow to the digestive tract (the superior mesenteric artery) directly and continuously in unanaesthetized, healthy humans. Several research groups have demonstrated how blood flow to the tract increases gradually and markedly after a meal, and more so after a big meal than after a small one. The increase in blood flow reaches its maximum after 20-40 minutes and lasts for 1.5-2 hours. In the postprandial period there is a parallel and similar increase in cardiac output; the meal thus imposes an increased work load on the heart. Carbohydrate meals, as well as meals of protein or fat all release increases in local blood flow as well as in cardiac output. Surprisingly, during physical exercise of relatively high intensity, there is no reduction in blood flow to the digestive tract in humans. This is in contrast to the exercise-caused flow reduction observed in several animal species. In the postprandial state the large increase in cardiac output caused by muscular exercise is actually added to the increase already established by the meal. This course of events helps to explain why patients with angina pectoris are more prone to chest pains after a meal.

[Bouveret's syndrome: the clinical and radiological findings]

Bouveret's syndrome is an unusual presentation of gallstone ileus, due to duodenal obstruction. It is produced by the migration of biliary calculus through a cholecystogastric or cholecystoduodenal fistula. We present 3 new cases of Bouveret's syndrome, and the clinical and radiological findings on different imaging procedures (plain abdominal radiography, barium studies, ultrasonography and computed tomography). On the basis of these cases, we discuss the diagnostic and possibly therapeutic merits of digestive endoscopy and about the different surgical procedures.

Patient doses from barium meal and barium enema examinations and potential for reduction through proper set-up of equipment

Patient doses for barium meal and barium enema examinations, performed at two Greek hospitals, were measured using a dose-area product meter. The results were analysed to obtain the contributions of fluoroscopy and radiography to the dose as well as a number of other dose related parameters for each examination. The doses observed are within the range of values reported by other authors and comply with the dose reference levels (DRLs), proposed from relevant surveys in the UK and The Netherlands. However, comparison between the two hospitals revealed significant differences in the contributions to dose from the various parts of the examinations. To determine the reasons for these differences, measurements of dose related parameters were made using a Plexiglas phantom and standard clinical X-ray machine settings. Factors contributing to increased dose delivery were determined and recommendations have been made concerning ways in which doses might be reduced in each hospital, without degradation of the diagnostic quality of these examinations.

Whole-body 18F-FDG PET for the evaluation of patients with Hodgkin's disease and non-Hodgkin's lymphoma

Whole-body metabolic information provided by 18F-FDG PET could help in the evaluation of lymphoma patients at diagnosis and follow-up. We studied 60 patients, 42 at initial presentation and 18 for disease recurrence (23 aggressive non-Hodgkin's lymphoma, 21 low-grade non-Hodgkin's lymphoma and 16 Hodgkin's disease). All patients underwent a clinical examination, computed tomography (CT) and a non-attenuated PET scan within 1 week. The patients received 222-296 MBq (6-8 mCi) 18F-FDG intravenously and emission scans were recorded 45-90 min later. 18F-FDG PET detected more lymph nodes than the clinical examination or CT, but this rarely resulted in upstaging (two patients). The concordance between PET and CT for the evaluation of the spleen, liver and digestive tract was quite good. Discordance was noted in 12 patients for the evaluation of bone marrow infiltration, but confirmation by MRI or focal biopsy was not always obtained. We conclude that non-attenuated 18F-FDG PET is an easy and efficient whole-body method for the evaluation of patients with lymphomas. Compared with conventional techniques, however, it does not appear to offer much improvement for staging but provides a satisfactory base for follow-up.

Gas at abdominal US: appearance, relevance, and analysis of artifacts

PURPOSE

To describe the spectrum of ultrasonographic (US) appearances of intraluminal gas, including two clinically relevant gas artifacts.

MATERIALS AND METHODS

Observations were made in patients and reproduced in an animal model, an ex vivo gut preparation, and a tissue-mimicking phantom. Appearances were classified according to a physical model of the interaction between sound and collections of gas.

RESULTS

Free bubbles of gas appeared as bright echogenic foci extending artifactually owing to lateral and axial blooming. This causes bubbles that abut the gut wall to enhance the layer one echo, which corresponds to the interface between the mucosa and the luminal contents. Such bubbles can also falsely appear to be within the gut wall itself owing to elevation averaging and thereby cause the artifact pseudo-pneumatosis intestinalis. Isolated groups of small bubbles created a characteristic periodicity and tapering of the distal echo pattern. In the extreme case, in which many such echoes are superimposed, "dirty shadowing" occurs. A contiguous pocket of gas may cause the gut wall to appear artifactually thickened (i.e., pseudo-thickened gut). This was shown to be a form of mirror image artifact.

CONCLUSION

Classification of the effects of gas on US images according to their physical characteristics may aid in their interpretation. Appreciating two previously undescribed artifacts, pseudo-pneumatosis intestinalis and pseudo-thickened gut, will improve the usefulness of abdominal US.

Mechanism of inhibitory effect of glucagon on gastrointestinal motility and cause of side effects of glucagon

Glucagon is commonly used during gastrointestinal examinations for the temporary inhibition of gastroduodenal movements. Three preparations of glucagon are now clinically available: those prepared by extraction from the pancreas (GL-P), by chemical synthesis (GL-S), and by genetic recombination (GL-G). The aim of this study was examine the mechanism of the inhibitory effect of glucagon on gastrointestinal motility and the cause of its side effects by comparing three glucagon preparations. In four conscious dogs, gastrointestinal contractions were monitored by means of chronically implanted force transducers. Each glucagon preparation (GL-P [15 microg/kg], GL-S [5, 15, 45 microg/kg], GL-G [15 microg/kg]), scopolamine butylbromide (0.4 mg/ kg), or saline was administered intravenously 20 min after the termination of spontaneous phase III contractions, and blood samples were taken at 5- to 10-min intervals. Barium was administered into the stomach 10 min after the infusion of each drug. The arrival of a barium meal in the stomach immediately stimulated gastrointestinal contractions, and the barium meal was expelled into the duodenum and jejunum from the stomach. Intravenous injection of 15 microg GL-S first stimulated duodenal contractions that propagated to the jejunum, followed by strong inhibition of the barium-induced gastrointestinal contractions. This inhibitory effect of glucagon and the activity of the glucagon-induced duodenal contractions were dose-related. The inhibitory effects of GL-G and GL-S were stronger than that of GL-P. Blood glucose and plasma insulin concentrations were raised after intravenous injection of each glucagon preparation, but there was no difference among the three preparations and no dose relationship. The inhibitory effects of glucagon depend on the material purity and dose, and the inhibitory mechanism was independent of any effect on carbohydrate metabolism. Glucagon administration caused phase III-like contractions in the duodenum and jejunum, which may be responsible for the side effects of glucagon.

[Lesions of hollow organs in closed abdominal trauma--the value of computerized tomography]

INTRODUCTION

evaluation of the clinical and radiological criteria for laparotomy in intestinal lacerations after a blunt abdominal trauma. Determination of the different radiological signs from the CT scan and the sensitivity of this examination in the diagnosis of intestinal lacerations.

DESIGN

retrospective study.

MATERIAL AND METHOD

we selected all patients operated for intestinal laceration caused by a blunt abdominal trauma during the period of 1986 to 1995. The clinical and radiological criteria for laparotomy in these patients were determined. Correlation of the radiological signs from the CT-Scan and the surgical findings was used to determine the sensitivity of the CT-scan. We distinguished patients who had an abdominal CT-scan from those patients for which no CT was done.

Foreign body ingestion in children: an audit of transit time

OBJECTIVES

To study the pattern of ingestion of radio-opaque foreign bodies in children and to ascertain the average transit time to passage per rectum in order to rationalise future management.

METHODS

This prospective study consisted of 100 children under the age of 14 years, presenting to the accident and emergency department of the Royal Aberdeen Children's Hospital having ingested a radio-opaque foreign body. All children had initial radiography and were subsequently followed up in an attempt to ascertain the transit time of the foreign body.

RESULTS

The majority of ingestions (73%) were in younger children (5 years and under). The time taken to pass the foreign bodies per rectum varied greatly. Almost half were never recovered. Transit time appears to increase with age. Three children were given oral cisapride to increase gastric motility after prolonged retention in the stomach.

CONCLUSIONS

Transit time is very variable and cannot be predicted. Sifting of the stools is unpleasant and unhelpful. Repeat radiography should not be encouraged as this results in unnecessary radiation. Cisapride may be useful in cases where there is prolonged retention of a foreign body in the stomach. There may be an indication for routine use of cisapride in all cases of ingested foreign bodies, however further audit would be required.

[Spontaneous esophageal rupture after gastrointestinal examination using barium]

We experienced a case of spontaneous rupture of the esophagus after gastrointestinal examination using barium. A 48-year-old male experienced severe chest pain after vomiting following gastrointestinal examination. Chest X-ray revealed a right pneumothorax and pleural effusion by barium. We diagnosed spontaneous rupture of the esophagus and performed right thoracotomy 6 hours after onset of symptoms. At 10 cm above the diaphragm, there was a vertical perforation 3 cm in length. Following saline lavage, the ruptured esophageal wall was directly closed by the layer to layer method. The post operative course was uneventful and the patient was discharged 3 weeks after surgery. Cases of spontaneous rupture of the esophagus into the right thoracic cavity induced by gastrointestinal examination are extremely rare.

[Current status and perspectives of conventional radiologic diagnosis of the gastrointestinal tract]

In the last twenty years the basic gastro-intestinal diagnostic procedures have had to record increasing losses. This is why the study of these examinations had becoming more and more endangered. From our experience and from literature review the question arises whether now or in future we can manage without the basic gastrointestinal diagnostic procedures. The answer is that both for efficiency and for costs the continuation of these procedures does not appear acceptable. The preservation of the X-ray techniques of examination should be object of discussion and agreement between radiologists, clinicians, endoscopists, and economically experienced professionals in administration. In order to meet the needs for urgent economic measures in hospitals, the increased use of investigation with water-soluble contrast media seems unavoidable. Therefore the examination techniques should be adjusted and optimised as described.

Brillo pad crack screen aspiration and ingestion

Crack cocaine is commonly smoked in a pipe with a metallic filter made from a steel wool scouring pad. We report an unusual complication of smoking crack cocaine: the aspiration and ingestion of a Brillo pad filter. A 34-year-old female presented 7 h after drinking beer and smoking crack. She was concerned that she might have inhaled the "screen" from her crack pipe, a piece of Brillo pad the size of her fingertip. She complained of "burning" in her throat, a foreign body sensation, and change in her voice, but no dyspnea, dysphagia, or abdominal pain. On physical examination, she was afebrile with a pulse of 105 beats/min and respiratory rate of 24 breaths/min. She was tearful and spoke in a whisper. There were no visible oropharyngeal burns and the lungs were clear to auscultation, but she had intermittent inspiratory stridor. The O2 saturation was 96%, and the ethanol concentration was 100 mg/dl. No foreign body or burn was seen on indirect laryngoscopy. A lateral neck x-ray study showed a normal epiglottis and no foreign body. Chest x-ray studies were unremarkable. Fiberoptic laryngoscopy showed left posterior arytenoid edema and swelling. An abdominal x-ray study revealed a foreign body in the right lower quadrant consistent with the Brillo pad filter. The next morning, the patient was asymptomatic and was discharged, recovering without sequellae. While crack pipe screen aspiration is a rarely reported event, physicians should be aware of the potential for foreign body aspiration and ingestion by this mechanism.

[Early endoscopic findings of the upper respiratory and digestive tract in patients undergoing translaryngeal intubation for more than 24 hours]

The large number of patients undergoing translaryngeal intubation justifies acquiring full knowledge of the complications that this invasive procedure may produce. The short-term problems that cause immediate complications (esophageal intubation, cuff rupture) are severe and do not escape notice. However, less immediate problems often pass undetected, although their presence may worsen the patient's outcome. Endoscopy allows the condition of the upper respiratory and digestive tract to be examined in order to detect and correct such problems. In this preliminary study, risk factors are analyzed and the lesions are described, classified, and quantified. Forty-seven adult patients were studied prospectively. In the first 24 to 48 hours of intubation, rigid endoscopy was performed under sedation using 0 degree and 30 degrees rigid endoscopes. The high rate of glottic edema (63.8%) was noteworthy because knowledge of this condition can be vital for preventing extubation failure.

[Unconventional imaging techniques in inflammatory bowel diseases]

In patients with inflammatory bowel disease (IBD), radiologic examinations are important for diagnosis and treatment. With conventional X-ray examinations, mucosal abnormalities, ulcers and fistulas can be visualised, but no information on the extramural extension of the disease can be obtained. Newer radiologic modalities (ultrasound, CT and MRI) offer new diagnostic possibilities. With ultrasound IBD can be diagnosed with good confidence and it can differentiate between Crohn's disease and ulcerative colitis. CT and MRI are indicated not so much to diagnose the disease but rather to determine the severity and spread of disease activity (transmural and extramural inflammation) and to detect complications such as fistulas and abscesses.

Effects of acepromazine and butorphanol on positive-contrast upper gastrointestinal tract examination in dogs

OBJECTIVE

To determine whether acepromazine (ACE) and butorphanol (BUT) combination can be used for restraint of dogs during positive-contrast upper gastrointestinal tract (UGIT) examination.

ANIMALS

6 healthy dogs.

PROCEDURE

In a randomized crossover design study, weekly UGIT examinations were performed on each dog for 5 weeks after administration of normal saline solution (0.5 ml), xylazine (1.0 mg/kg of body weight), or a combination of ACE (0.1 mg/kg) and 1 of 3 doses of BUT (0.05, 0.2, 1.0 mg/kg). Gastrointestinal tract emptying time, GI motility, pulse, respiratory rate, and quality of restraint were assessed.

RESULTS

Total gastric emptying time was significantly prolonged by use of an ACE and BUT (0.05 mg/kg) combination. Xylazine and higher dosages of BUT significantly prolonged gastric and intestinal emptying times. All anesthetic protocols significantly decreased motility and facilitated nonmanual restraint. Xylazine and BUT (1.0 mg/kg) significantly decreased pulse and respiratory rate.

CONCLUSION

The ACE and BUT combination prolonged GI tract emptying times, decreased GI motility, and facilitated nonmanual restraint for duration of the examination. Although GI motility was decreased and total gastric emptying time was prolonged, administration of ACE (0.1 mg/kg) plus BUT (0.05 mg/kg) allowed morphologic examination of the GI tract within 5 hours. Xylazine prolonged GI tract emptying, decreased GI motility, and provided good to excellent initial restraint. Clinical Relevance-The ACE and BUT combination prohibits functional examination of the GI tract; however, morphologic examination is possible when low dosages of BUT (0.05 mg/kg) are used.

Sonographic borderlands in the fetal abdomen

Ultrasonographic examination of the fetal abdomen is an integral part in all routine fetal sonograms and can provide significant information about the status and prognosis of the fetus. Although many types of fetal anomalies can be identified (i.e., gastroschisis, omphalocele, or congenital diaphragmatic hernia), there are several sonographic findings that are not clearly anomalous, but may be associated with poor fetal outcome. Echogenic fetal bowel, small or absent fetal stomach and fetal intra-abdominal calcifications all fall into this category. This article reviews the recent literature as it relates to these topics, including suggestions regarding the need for further action, and the types of further actions that are available to help identify abnormal fetuses and prevent unnecessary and/or invasive testing of normal ones.

Endoscopic ultrasound. Diagnostic and therapeutic uses

Endoscopic ultrasound (EUS) is an emerging technique that can be used to visualize lesions in or adjacent to the gastrointestinal tract. We performed a review of current indications and capabilities of endoscopic ultrasound. EUS provides diagnostic information on submucosal lesions of the gastrointestinal tract. It is the most accurate method for local staging of esophageal and rectal cancer. It appears to be more sensitive in detecting common bile duct stones than endoscopic retrograde cholangiopancreatography. Furthermore, its use avoids the risk of pancreatitis. Lesions deep to the gastrointestinal tract, such as mediastinal nodes or pancreatic lesions, can be biopsied through the EUS endoscope. New therapeutic uses of EUS include aid in endoscopic drainage of pancreatic pseudocysts and celiac axis neurolysis for the treatment of pain from pancreatic cancer. EUS offers many new diagnostic capabilities to visualize and biopsy lesions in or adjacent to the gastrointestinal tract. Therapeutic uses are also emerging for this new technique.

Improved retroperitoneal and gastrointestinal sonography using oral contrast agents in a porcine model

OBJECTIVE

Abdominal sonography can be compromised by the presence of air within the scanning field. Gas-displacing oral contrast agents have the potential to improve the diagnostic yield of routine abdominal sonography. The purpose of this study was to investigate two oral contrast agents and water and to compare their ability to improve abdominal sonography with an unenhanced baseline study and each other in a porcine model.

MATERIALS AND METHODS

The acoustic properties of agent 1 (Oralex; Molecular Biosystems, San Diego, CA), a suspension of polydextrose in purified water; agent 2, a homemade agent (named BMW), a suspension of polysaccharide particles in water; and water were assessed in finger phantoms under laboratory conditions. Each solution was subsequently evaluated in 10 pigs, for a total of 30 animals. The bolus character, gas artifact, abdominal viscera, vessels, and gut wall were graded from 1 (nondiagnostic) to 5 (excellent) in the unenhanced and postcontrast states. Postcontrast grades were compared with unenhanced baseline grades using the Wilcoxon signed-rank correlation. Agents were compared with each other using the Mann-Whitney U test (Wilcoxon rank sum test).

RESULTS

All three solutions were hypoechoic, were homogeneous, and showed minimal attenuation and backscatter. Both oral contrast agents had excellent bolus characteristics (agent 1, grade 5.0 +/- 0; agent 2, grade 4.6 +/- 0.5), displaced gas from the scanning field, and significantly improved visibility in all categories, particularly the gut. No difference in performance was found between agents 1 and agent 2. Water had poor bolus characteristics (grade 1.3 +/- 0.48) and did not improve visibility over baseline.

CONCLUSION

The acoustic in vitro properties of agent 1 and agent 2 approach that of an ideal sonographic contrast agent. Both agents are superior to water in their improvement of direct visualization of the retroperitoneum and the gut in abdominal sonography in a porcine model.

Dilemmas in the diagnosis of blunt enteric trauma

Early identification of enteric injuries following blunt trauma relies on clinical examination, diagnostic peritoneal lavage (DPL), and/or computed tomography (CT) scan. Limitations in each approach may result in diagnostic delays and potentially increased complications. The purpose of this study was to evaluate the ability of early DPL and CT scans in identifying enteric injuries requiring surgical repair and to determine the impact of injury time to definitive repair on complication rates. A retrospective review of patients admitted to the Butterworth Hospital Level I Trauma Center between January 1, 1990 and December 31, 1996 identified 69 appropriate patients. Three study groups were treated as follows: laparotomy on clinical examination (N = 7), laparotomy after initial DPL (N = 28), and laparotomy after initial CT (N = 34). Early DPL missed 5 (18%) enteric injuries, which was significantly fewer than the 13 (38%) missed by CT scan. Review of these 13 CT scans revealed 6 examinations not suggesting enteric injury and 7 with signs suggestive of injury. Four injuries missed by CT subsequently were found by delayed DPL. Morbidity rates in either group increased when injury time to definitive repair was >24 hours (18-50%). The results indicate that early DPL and CT have limitations in blunt enteric injuries. However, morbidity and mortality rates did not increase until repair was delayed >24 hours postinjury. Also, delayed DPL successfully identified these injuries in four patients after negative CT. Therefore, in patients at high risk for enteric injuries, there may be a role for delayed or repeat DPL after an initially negative DPL or CT.

A comparison of patient dose for examinations of the upper gastrointestinal tract at 11 conventional and digital X-ray units in The Netherlands

The objective of this study was to derive the effective dose to patients from examinations of the upper gastrointestinal (GI) tract at 11 X-ray units in 10 Dutch hospitals. Entrance dose and entrance dose rate were measured at the surface of a homogeneous PMMA phantom and at the entrance surface of the image intensifier. Dose-area products (DAPs) were assessed during examinations of patients. The patients (334 females and 256 males) ages were 18-95 years (average 52 years). Effective dose was assessed from DAP using Monte Carlo computer calculations for male and female mathematical anthropomorphic phantoms. The DAPs measured during the survey showed substantial variations, i.e. an overall average value of 21 Gy cm2 and a range of average DAP per X-ray unit varying from 7 to 56 Gy cm2. Variations in the number of images (8-28) and the fluoroscopy time (1.7 min-7.0 min) were also large. A DAP to effective dose conversion factor of 0.32 mSv Gy cm-2 was derived for upper GI studies. The dose survey yielded an overall average effective dose of 6.7 mSv. At one location an examination involving as many as 28 projections was performed, whilst maintaining a DAP well below 15 Gy cm2 and an effective dose below 6 mSv. This was achieved using modern equipment (i.e. high frequency generator, digital spot films) with 0.2 mm additional copper filtration and a relatively high tube voltage. For examinations of the upper GI tract, the application of a reference value of 30 Gy cm2 for the DAP will ensure that, in general, the effective dose to individual patients will not exceed 15 mSv.

Ultrasonic research of abdominal organs in conditions of long-term antiorthostatic hypokinesia

Change in functional activity of digestive system in space flight usually is associated with phenomenon of hypokinesia which takes place in microgravity. However, it is marked that the reorganization of a gastrointestinal tract in space flight occurs on a background of the phenomenon of venous plethora in abdominal cavity, which can also result in changes of functional activity in organs of digestive system. Insignificant amount of studies of venous plethora in abdominal cavity carried out in conditions of space flight does not allow to create a complete picture of this phenomenon. Hemodynamical changes comparable to microgravity are well-simulated in conditions of a long-term antiorthostatic hypokinesia (AH)--bed-rest in a head-down tilt. The present research was performed with the aim to study venous plethora in abdominal cavity in conditions of long-term AH.

Characterization of gastrointestinal tumors

Transabdominal ultrasonography is used increasingly for the evaluation of gastrointestinal disorders in small animals, including neoplasms such as lymphosarcoma, carcinoma, and smooth muscle tumors (leiomyoma, leiomyosarcoma). An updated summary of the clinical studies currently investigating the use of ultrasonography to detect and to characterize gastrointestinal neoplasia is presented in this article.

Blunt abdominal trauma in adults: role of CT in the diagnosis and management of visceral injuries. Part 2: Gastrointestinal tract and retroperitoneal organs

Computed tomography plays an important role in the detection and management of blunt visceral injuries in adults. Current standard examination techniques enable detection of the majority of perforating or devascularizing bowel injuries, although diagnostic findings are often subtle and meticulous inspection is required. Computed tomography may demonstrate pancreatic contusions and lacerations and help in distinguishing minor traumatic lesions without involvement of the pancreatic duct (organ injury scale, grades I and II) from deep lacerations with ductal involvement (grades III and V). Computed tomography enables distinguishing renal contusions and minor cortical lacerations that can usually be managed conservatively (injuries of grades I-III) from corticomedullary lacerations and injuries of the major renal vessels (grades IV and V) that have a less favorable prognosis and more commonly require surgical repair. In addition, CT is well suited for the detection of active renal hemorrhage and guidance of transcatheter embolization treatment and delineation of preexisting benign or malignant pathologies that may predispose to posttraumatic hemorrhage. The radiologist's awareness of the diagnostic CT findings of abdominal visceral injuries as well as their clinical and surgical implications are important prerequisites for optimal patient management.

Prenatal diagnosis of gastrointestinal anomalies with ultrasound. What have we learned?

The use of routine obstetric ultrasound has been shown to accurately diagnose fetal gastrointestinal anomalies, both during and after the midtrimester. These are among the most accurately diagnosed of all anomalies, comprising 5-7% of all fetal anomalies. From a review of the literature it is clear that the use of routine ultrasound allows: (1) the detection of multiple anomalies that are often present and affect outcome significantly, (2) preparation for delivery at a tertiary center where neonatal surgical experience will allow optimal outcome, and (3) decisions about mode and timing of delivery in cases where this is important, i.e., cases of omphalocele and gastroschisis.

Percutaneous sonographic gastrostomy: method, indications, and problems

OBJECTIVES

This study evaluated the application of ultrasound (US) guidance in the percutaneous placement of gastric feeding tubes in patients in whom endoscopic placement of a nutrition tube is not possible.

METHODS

Thirty-eight patients with upper gastrointestinal obstruction were entered in a prospective study with US-guided nutrition tube application. Feasibility of placement, side effects, and nutritional states were monitored for a mean follow-up of 4 months.

RESULTS

Ultrasound allowed rapid puncture after filling of the stomach with water through a nasal tube in 34/38 cases. In four cases a total upper gastrointestinal obstruction required an initial stomach insufflation through a direct puncture. Puncture-related major complications were not observed. Minor complications during the observation time were one late dislocation, five cases with broken material after about 6 months (four could be changed by using the Seldinger technique), and two minor local infections. The nutrition through feeding tubes stabilized body weight and body composition parameters.

CONCLUSION

The percutaneous sonographic gastrostomy (PSG) is a safe and minimally invasive procedure for enteral nutrition in all cases with upper gastrointestinal obstruction when endoscopic placement of a feeding tube is not possible. Percutaneous sonographic gastrostomy may help to stabilize the nutritional parameters and general condition in patients with malignant diseases.

The radiodensity of medications seen on x-ray films

OBJECTIVE

To analyze the radiodensity of commonly used medications and determine their ability to be seen on plan x-ray films.

MATERIAL AND METHODS

Under conditions intended to simulate a patient undergoing radiography of the abdomen (including the use of a patient-equivalent phantom), 50 prescription and nonprescription drugs were tested. Their radiodensities were quantified, and their visibility on plain x-ray films was noted. The study drugs were then ranked in order of decreasing radiodensity. In addition, we report an illustrative case of ingested pills in the stomach that mimicked gallstones, a phenomenon we termed "pseudogallstones".

RESULTS

In a 71-year-old woman with upper abdominal pain and nausea, a presumptive diagnosis of gallstones based on x-ray findings was subsequently found to be retained iron tablets. This case prompted our assessment of the radiodensity of medications frequently prescribed for elderly patients. Although all 50 medications studied were visible on plain x-ray films, a 13-fold difference was found in their relative radiodensities. Of the medications studied, potassium chloride was the most radiodense, and prednisone was the least radiodense. As a group, minerals were the most radiodense of all medications studied.

CONCLUSION

Numerous commonly prescribed medications in their undissolved, undigested state are visible on plain x-ray films, as are mineral supplements, which have high radiodensities. At times, the appearance of these medications and supplements may be confused with organic pathologic conditions.

[Evaluation of the effects of bioadhesive substances as addition to oral contrast media: an experimental study]

PURPOSE

To evaluate the additional effect of bioadhesives in combination with iotrolan and barium as oral contrast media in an animal model.

METHOD

The bioadhesives Noveon, CMC, Tylose and Carbopol 934 were added to iotrolan and barium. The solutions were administered to rabbits by a feeding tube. The animals were investigated by computed tomography (CT) and radiography after 0.5, 4, 12, 24 and in part after 48 hours. Mucosal coating and contrast filling of the bowel were evaluated.

RESULTS

Addition of bioadhesives to oral contrast media effected long-term contrast in the small intestine and colon, but no improvement in continuous filling and coating of the gastrointestinal tract was detected. Mucosal coating was seen only in short regions of the caecum and small intestine. In CT the best results for coating were observed with tylose and CMC, in radiography additionally with carbopol and noveon. All contrast medium were well tolerated.

CONCLUSION

The evaluated contrast medium solutions with bioadhesives have shown long-term contrast but no improvement in coating in comparison to conventional oral contrast media.