Colorectal carcinomas: diagnostic implications of their changing frequency and anatomic distribution

This retrospective review included 1,694 consecutive cases of colorectal carcinoma diagnosed at the University of Chicago Medical Center during a 25-year period (1960 through 1984). The number and percentage of tumors occurring within 7 anatomic segments of the large bowel were determined. The statistical data for a recent 5-year interval were then compared with those of the 2 preceding decades. There was a 10.2% increase in the frequency of cancers originating in the cecum or ascending colon, while rectal and rectosigmoid carcinomas declined by 15.8% during the same study period. These data provide further evidence for a progressive left-to-right shift in cancer distribution within the colon during the past quarter century. Currently, the most proximal and distal 20-25 cm segments of the large bowel (cecum or ascending colon versus rectum and rectosigmoid) each harbor approximately 25% of the tumors. Therefore, the classic medical teaching that over 50% of colorectal cancers would be detectable by digital examination and/or proctosigmoidoscopy is no longer accurate. This documented increase in proximal colon cancers and redistribution of lesions within various large bowel segments indicate the growing importance of barium enema and colonoscopy as the optimal techniques for detection of colorectal neoplasms.

Heterotopic gastric mucosa in the duodenum: radiographic findings

Heterotopic gastric mucosa in the duodenal bulb was detected by endoscopic examination in 25 adult patients and was confirmed by biopsy in 17 of these patients. The endoscopic findings were correlated with the radiographic features of the lesion on upper gastrointestinal barium studies. On radiographs, this entity usually presented as clusters of 1- to 3-mm plaques raised above the smooth and featureless duodenal mucosa; this was seen in 17 (68%) of 25 patients. A less frequent finding was patches of coarse nodular mucosa with superficial erosions or an ulcer crater (five cases [20%]). The heterotopic gastric mucosa was visible as polypoid masses in two patients and as prominent areae gastricae covering the base of duodenal bulb in another.

Complications of endoscopic gastrostomy: pneumoperitoneum and volvulus of the colon

Pneumoperitoneum caused by percutaneous gastrostomy usually follows a benign clinical course, but led to progressive volvulus of the ileocolic segment in the patient described here. This article explains relationships between pneumoperitoneum after surgical or endoscopic procedures and volvulus involving the intraperitoneally mobile intestinal loops.

Crohn's disease of the duodenum complicated by adenocarcinoma

Patients with Crohn's disease of the small bowel or the colon are at risk for development of cancer within their chronically inflamed intestinal loops. We present here the first reported case of malignant degeneration of duodenal mucosa involved by Crohn's disease. The clinical observations as well as radiographic and endoscopic features of this unusual complication are described.

Appendicitis as the initial manifestation of Crohn's disease: radiologic features and prognosis

Twenty-five patients 15-47 years old presented with appendicitis as the initial manifestation of Crohn's disease. This entity accounted for 1.8% of all appendicitis patients undergoing surgery at our institution during a recent 9-year period. Preoperative radiologic studies in 18 (72%) of 25 cases showed abnormalities indicating the presence of appendicitis or periappendiceal abscess, but not the specific diagnosis of Crohn's disease as the underlying cause. Histopathologic evidence for an isolated, transmural, or granulomatous appendicitis was found in 20 patients; in two of these there was a local recurrence within 3 years after surgery, while 18 others have remained asymptomatic during follow-ups of up to 8 years. In the other five patients Crohn's disease caused appendicitis with concurrent inflammation of the cecum or terminal ileum; three of these cases were complicated by progressive granulomatous ileocolitis within 2 years. The data presented herein indicate that Crohn's disease can originate in and be confined to the appendix, yet manifest clinical symptoms leading to emergency laparotomy; preoperative radiologic findings are similar to those of suppurative appendicitis, but visualization of a markedly thickened appendiceal wall with patent or irregularly narrowed lumen supports the diagnosis of Crohn's appendicitis; and primary Crohn's disease of the appendix has a favorable long-term prognosis after simple appendectomy, despite a 10% incidence of recurrence as granulomatous ileocolitis.

Laminated radiopaque enteroliths: diagnostic clues to intestinal pathology

Laminated intestinal calculi were detected during radiographic evaluation of the abdomen in 14 adult patients. These enteroliths had developed in the distal ileum of 12 patients who had either a Meckel's diverticulum (four cases) or a variety of other lesions causing local stasis, including strictures due to Crohn's ileitis, ileocecal tuberculosis, radiation enteritis, and peritoneal adhesions. Only two patients had enteroliths in the colon proximal to strictures complicating ulcerative colitis. The clinical and radiological features of enterolithiasis as well as the mechanism of its formation are herein described.

CT diagnosis of occult incisional hernias

CT of the abdomen was performed on 14 adult patients 2-25 months after laparotomy in order to evaluate intraabdominal processes. Clinically unsuspected incisional hernias were detected in all cases. These herniations were not disclosed by previous physical examination because of the patients' obesity, abdominal pain, distension, or various other factors. However, CT scans showed the exact size, location, and content of each incisional hernia. The evaluation of postsurgical abdomen by CT should include a careful assessment of previous laparotomy sites in search of occult incisional hernias that may be the source of the patient's abdominal symptoms.

CT demonstration of fistula between esophageal carcinoma and spinal canal

A patient with recurrent carcinoma of the proximal esophagus after radiotherapy presented with bacterial meningitis. Esophagography and CT of the chest disclosed an esophagosubarachnoidal fistula extending between the ulcerated tumor, posterior mediastinum, and the thoracic spine.

Nasoenteric feeding tubes. Radiographic detection of complications

Recent technical refinement of feeding tubes and formula infusion pumps has led to widespread clinical use of long-term nasoenteric alimentation. We evaluated 340 hospitalized adults after placement of flexible, small-bore feeding tubes. These debilitated or critically ill patients were intubated transnasally at their bedside without fluoroscopic guidance, but portable radiographs of the chest and abdomen were obtained routinely for tube localization before administering liquid nutrients. Various complications were detected in 26 cases (7.6%). Tube malposition into the airways (seven patients) or within the pharynx and esophagus (eight patients) was the most common problem; it occurred in 4.4% of all cases. Radiographic findings in 11 other patients included tube-induced perforation of the lung (one case), massive aspiration (three), malfunction of knotted tubes (three), and rupture of their mercury capsule within the gastrointestinal tract (four). Our observations indicate a need for careful radiographic localization of the feeding tubes at the time of insertion and their periodic monitoring throughout the course of nasoenteric alimentation.

Duodenal manifestations of nontropical sprue

Barium studies of the upper gastrointestinal tract and small bowel were performed in 16 adult patients with biopsy-proven nontropical sprue. Commercially available contrast media containing micropulverized barium sulfate, suspending agents, and various other additives were used. Radiographs were analyzed for the incidence and pattern of duodenal vs. small-bowel changes associated with celiac disease. Thirteen of 16 patients (81%) demonstrated abnormalities of the duodenum which ranged from focal erosions to diffusely thickened and nodular folds. A nonspecific, mild dilatation pattern was present on the small-bowel series of 11 patients (69%). The classic radiographic signs of malabsorption, such as flocculation and segmentation, however, occurred in less than 20% of cases, apparently because of the stability of new barium suspensions. The pathogenesis of duodenal changes in sprue and its diagnostic implications are emphasized.

Arteriographic evaluation of postsurgical stomach

Visceral arteriography was performed in 35 adult patients who had undergone various types of gastric surgery. Nineteen of these patients had presented with gastrointestinal hemorrhage at different postoperative intervals (4 days-23 years). Arteriography showed the bleeding site in 14 (74%) and permitted its nonoperative control in 8 cases. Diffuse hemorrhage from the gastric pouch as well as localized bleeding from suture line, marginal or stress ulcers, and other sources were recognized. Arteriography was also crucial in the diagnosis of iatrogenic arteriovenous fistulas, telangiectasia in the anastomotic regions, inadvertently ligated arteries, and postoperative changes in the vascular architecture. Value and limitations of arteriography of the postsurgical stomach are presented together with a review of the pertinent literature.

Radiation-induced esophageal carcinoma

Radiation-induced carcinoma of the esophagus is rare and only 8 cases have been reported since 1957. This article presents 2 additional patients in whom esophageal carcinoma developed in segments previously exposed to large therapeutic doses of irradiation. The first patient had received 5,000 rads to her mediastinum and the second patient 3,200 rads to her neck region. The latent intervals were 11 years and 30 years, respectively.

Glycogenic acanthosis of the esophagus: radiographic and pathologic features

Diagnostic features of glycogenic acanthosis of the esophagus on air-contrast radiography, endoscopy, and histopathologic studies in 10 selected cases are presented. Glycogenic acanthosis of the esophagus is a common benign entity, characterized by multifocal plaques of hyperplastic squamous epithelium with abundant intracellular glycogen deposits. At esophagoscopy or on autopsy specimens these lesions appear as slightly raised grey-white plaques which are usually 2-10 mm in diameter and may be confluent. They cause a finely nodular or cobblestone mucosal pattern demonstrable on double-contrast views of the well-distended esophagus. The findings are not associated with mucosal ulcerations, luminal narrowing, or mobility disturbance, although some patients may have coexistent hiatal hernia and gastroesophageal reflux.

Burkitt's lymphoma of the stomach

An unusual case of American Burkitt's lymphoma originating in the stomach of an elderly man is presented. Computed tomography revealed diffuse infiltration of the gastric wall by a solid tumor measuring 2.5 to 5.5 cm in thickness. Despite such bulky tumor, however, distensibility of the stomach was preserved because Burkitt's lymphoma does not induce desmoplastic reaction and linitis plastica.

Internal abdominal hernias

Internal hernias are the underlying cause of acute or intermittent intestinal obstruction in approximately 4 per cent of cases. Their preoperative diagnosis depends on radiologic evaluation of the gastrointestinal tract with contrast material. This article presents the clinical and radiographic findings associated with various types of intra-abdominal herniations.

Prolapsing inflammatory pseudopolyp-fold complex of the oesophagogastric region

This article describes a series of 12 adult patients in whom a prominent and mobile polypoid fold of the oesophagogastric region was demonstrated radiologically. Subsequent endoscopic and histopathologic studies confirmed the presence of an inflammatory pseudopolyp at the squamocolumnar junction and contiguous with a thick gastric rugal fold. The clinical and radiographic features of this entity and the mechanisms of its formation are reviewed.

Lymphoma of the stomach following gastric surgery for benign peptic ulcers

Adenocarcinoma of the gastric stump is a well-known complication of gastroduodenal surgery for benign lesions. However, we report 2 unusual cases wherein malignant lymphoma originated in the postoperative stomach. The first patient had undergone partial gastrectomy and Billroth II procedure 20 years earlier. The gastric lymphoma of the second patient manifested 39 years after vagotomy and pyloroplasty. In both instances, the tumor caused marked thickening and nodularity of the rugal folds without affecting the distensibility of the previously operated stomach. Differential diagnostic features of the observed findings and the potential carcinogenic effects of gastroduodenal surgery are reviewed.

Diagnosis and management of intraluminal duodenal diverticulum

The descending part of duodenum is the principal site for an intraluminally projecting mucosal pouch or diverticulum, but this unusual lesion may also occur elsewhere in the upper gastrointestinal tract. We report three patients in whom a large intraluminal duodenal diverticulum (IDD) was diagnosed radiographically at the ages of 15, 27, and 68 years, respectively. Fiberoptic duodenoscopy was performed in the two symptomatic cases for the removal of impacted food from IDD or dilatation of its outflow aperture. Guidelines for the diagnosis and treatment of IDD are provided based on our experience and review of the pertinent literature.

Esophageal manifestations of Crohn's disease

Two patients with concurrent esophagitis and ileocolitis due to Crohn's disease are presented. The initial feature of esophageal involvement was dysphagia caused by severe inflammation of the distal esophagus with mucosal ulcerations and polypoid folds. Long-term observation of both cases revealed a gradually progressive course leading to development of rigid esophageal structure, intramural sinus tract, and esophagobronchial or esophagogastric fistulas. The clinical and radiographic manifestations of Crohn's esophagitis in these 2 patients and in 18 previously reported cases are reviewed.

Reappraisal of contrast media used to detect upper gastrointestinal perforations: comparison of ionic water-soluble media with barium sulfate

Iodinated water-soluble compounds have been widely recommended as the most suitable contrast media for diagnosis of gastrointestinal perforations. However, the authors present 6 cases in which mucosal tears and transmural perforations of the upper gastrointestinal tract were either unrecognizable or inadequately shown during initial evaluation with methylglucamine diatrizoate. Re-examination with barium sulfate demonstrated the precise location and extent of the perforations. Reasons for the higher diagnostic yield of barium studies are explained on the basis of experimental and clinical observations.

Idiopathic localized dilatation of the ileum in adults

The clinical and radiological features of idiopathic aneurysmal dilatation of the ileum in 3 adult patients are described. This uncommon lesion presents as an aperistaltic saccular segment in direct continuity with the normal ileal lumen. On barium examination of the small bowel, however, it may closely resemble and be mistaken for a Meckel's diverticulum. Previous reports about this entity manifesting in the pediatric age group are reviewed.

Calcified pseudocyst of the pancreas

Pancreatic pseudocysts are encapsulated collections of fluid which may complicate trauma or inflammation of the pancreas. The correct preoperative diagnosis of the pseudocyst can be established easily by the modern techniques of ultrasonography or computed tomography (1-3). However, recognition of the lesion on plain radiographs of the abdomen is rarely possible because the wall and content of pancreatic pseudocysts do not show a visually perceptible difference in density from the adjacent soft tissues (4). This report concerns an exceptional instance whereby a pancreatic pseudocyst was clearly demarcated by virtue of radiographically detectable calcium deposits in its wall.