[MDCT features and anatomic-pathology in right thoracic-abdominal junctional region diseases]

This paper was objected to determine the relationship between MDCT features and anatomic-pathology of diseases in right thoracic-abdominal junctional region. We cut 3 cadavers transversely and another 3 vertically to observe the anatomy of thoracic-abdominal junctional zone. We scanned 69 patients with diseases in right thoracic-abdominal junctional zone by MDCT. The correlation between MDCT features of right thoracic-abdominal junctional region and the anatomic-pathology in this region was evaluated. We found results as that in cadaver sections, the right pulmonary ligament, which was below inferior pulmonary vein, attached the inferior lobe of right lung to the esophagus, that the coronary ligament, which interiorly extended from falciform ligament and laterally formed into right triangular ligament, contained two layers, and that the bare area of liver, which positioned between the two layers of coronary ligament, was directly next to diaphragm with no peritoneum covered. There were 50 cases with both pleural and ascitic fluid, while the pleural fluid was divided into anterior and posterior compartments by the right pulmonary ligament, whereas the ascitic fluid was limited in perihepatic space in majority. Among the 50 cases, 5 patients had lung cancer with diaphragmatic pleura, diaphragm and upper abdomen involved. 5 patients had right hepatic lobe cancer with subdiaphragmatic peritoneum, crura diaphragmatis and lower thoracic cavity involved. 1 patient had right adrenal carcinoma with phrenic metastasis. 8 patients had inflammation in right lower thorax and/or right upper abdomen. The spreads of these diseases include mainly direct invasion, blood and lymphatic spread routs in the region. Conclusion could be drawn that the MDCT features and distribution of right thoracic-abdominal junctional region diseases correlate with the anatomical characteristics in this region.

[Relaparotomy and laparostomy in treatment of early postoperative complications]

The cause-and-effect analysis of early (within 3 weeks after the initial surgery) relaparotomy was made, using the experience of 5286 laparotomized patients, of whom 82 (1,55%) had relaparotomy. The main reason of intraabdominal complications was the initial generalized peritonitis in emergency patients (85,4%). In comparison with data of 30 years prescription, the portion of postoperative peritonitis and bleeding had increased, though the number of eventrations and postoperative ileus, on the contrary, decreased. The introduction of laparoscopy eliminated the necessity of diagnostic relaparotomies. The mortality rate after the repeated surgery had decreased from 38,0% to 30,5%.

[Surgical treatment of the unformed intestinal fistulae]

Treatment results of 5 patients with unformed intestinal fistulae are represented. High unformed intestinal fistulae are acknowledged to be completely unsuitable for conservative treatment and should be operated on. Complex treatment should include complete parenteral feeding, adequate fecal diversion with the use of aspirational drainage. Surgical treatment must be y the increase of fistula discharge or absence of fistula formation. Low intestinal fistulae should better be surgically dissected after their organization, otherwise urgent surgery is to be performed by complications development, such as purulent leakage into the abdominal cavity or severe wound infection.

Lost intrauterine contraceptive device inserted 42 years before: a case report

OBJECTIVE

The management of a lost abdominal intrauterine contraceptive device (IUD) is discussed together with a review of the relevant literature.

THE CASE

The IUD is one of the most commonly used, effective, cheap and safe methods of contraception in Turkey. However, IUD insertion may result in uterine perforation which may lead to a variety of abdominal complications or can remain asymptomatic in the abdomen for a long time without causing any complications. An asymptomatic case of a woman with an IUD inserted 42 years before is presented. To the best of our knowledge this is the longest time an IUD (found by X-ray) has been localized in the abdomen.

CONCLUSION

We suggest that in asymptomatic patients with an IUD localized in the abdomen, the risks of both operating and not operating should be discussed thoroughly and in such cases, follow-up without surgery may be considered as an alternative approach.

[Comparison of the image quality of conventional and digital radiography in lizards. Mammography technique versus digital detector system]

OBJECTIVE

A conventional high-resolution screen-film system (Film Kodak MIN-R S, Kodak MIN-R 2000) was compared with an indirect digital detector system (Varian PaxScan 4030E) for use in radiography of lizards.

MATERIAL AND METHODS

A total of 20 bearded dragons (Pogona vitticeps ) with body masses between 123 g and 487 g were investigated by using conventional and digital image acquisition techniques. The digital image was taken with the same dose as well as half the dose of the conventional radiograph. The study was conducted semi-blinded as the x-ray images were encoded and randomised. Five veterinarians with clinical experience in reptile medicine served as observers. Exactly defined structures in three anatomical regions were assessed using a three-step scale. Furthermore, the overall quality of the respective region was evaluated using a five-step scale. Evaluation of the data was done by visual grading analysis.

RESULTS

None of the structures examined was assessed to be of significantly inferior quality on the digital images in comparison to the conventional radiographs. The majority of the results demonstrated an equal quality of both systems. For assessment of the lung tissue and the pulmonary vessels as well as the overall assessment of the lung, the digital radiographs with full dose were rated to be significantly superior in comparison to the film-screen system. Furthermore, the joint contours of the shoulder and cubital joints and the overall assessments of the humerus and the caudal coelomic cavity were rated significantly better on digital images with full dose compared to those with reduced dose.

CONCLUSIONS

The digital flat panel detector technique examined in this study is equal or superior to the conventional high-resolution screen-film system used. Nevertheless, the practicability of a dose reduction is limited in bearded dragons.

CLINICAL RELEVANCE

Digital imaging systems are progressively being used in veterinary practice. The results of the study demonstrate the useful application of the digital detector systems in lizards.

[Development of CT manifestations and anatomic studies on thoracic-abdominal junctional zone]

Thoracic-abdominal junctional zone is an area from the inferior chest to superior belly. The inferior chest contains inferior pulmonary lobes, pulmonary ligament, inferior mediastinum and lower thoracic cavity,while the superior belly contains upper abdominal cavity, spatium retroperitonaeale, abdominal aorta, inferior vena cava, liver, stomach, adrenal glands, kidneys and spleen. This article is to review the CT manifestations and anatomy of diseases such as infection, trauma, hemorrhage, hernia and tumor involving this area. It could provides anatomic and pathological information for instituting clinical treatments.

A bizarre abdominal cystic lesion

In spite of careful intraoperative precautions and gauze counts, mistakes can still occur during surgery. In the case reported, a retained gauze leaved during a surgical approach for removing a solid-cystic papillary tumor localized in the pancreatic tail, caused both persistent abdominal discomfort and the presence of an abdominal cystic lesion at imaging techniques. When a previous operative history is present, a foreign body should be taken into account in the differential diagnosis of a patient with an intra-abdominal cystic mass. Finally, radio-opaque marker should be routinely used by surgeons in order to reach a correct diagnosis in operated patients having retained gauze.

A bizarre reentry phenomenon of distal shunt tip causing shunt malfunction

INTRODUCTION

We report a bizarre presentation of a distal shunt malfunction in a 5-year-old child with a ventriculoperitoneal shunt.

DISCUSSION

The plain radiographs done as a workup for possible shunt malfunction demonstrated the distal shunt tip reentering the abdominal wall from inside the peritoneal cavity. We discuss the possible explanation for the phenomenon.

CONCLUSION

We conclude that the case is just another reminder of the fact that shunt malfunctions can have multiple presentations; hence, a regular follow-up with appropriate imaging and high index of suspicion is mandatory in preventing morbidities.

[Gas in the abdominal cavity--due to cholecystitis caused by gas-producing bacteria]

In most cases, gas in the abdominal cavity indicates perforation of the gastrointestinal wall. We describe a patient, in whom the cause of abdominal gas detected in computed tomography turned out to be emphysematous cholecystitis caused by gas-producing bacteria. It is a rare disease characterized by accumulation of gas into the gall bladder or its wall. The gas can be easily observed in computed tomography. The disease easily becomes complicated and is associated with high mortality. Prompt cholecystectomy and antibiotic therapy are the cornerstones of the treatment.

Usefulness of abdominal CT scan in severe peritoneal sepsis linked to primary peritonitis

We report 2 cases of primary group A streptococcal peritonitis in which emergency abdominal CT scan ruled out a hollow viscus perforation, or necrosis, avoiding unnecessary laparotomy. These cases highlight the usefulness of abdominal CT scan and suggest that blind surgical exploration has no advantages.

Mesenteric Doppler ultrasonography findings of Echinococcus multilocularis infection: an experimental study

The diagnosis of alveolar echinococcosis, caused by the larval stage of Echinococcus multilocularis, is often difficult and almost always possible only in the later stages of the disease. In this study, we aimed to evaluate the findings of Doppler ultrasonography images for the diagnosis of intraabdominal non-visceral alveolar echinococcosis in Meriones unguiculatus. Six infected animals were studied. Abdominal Doppler ultrasonography examinations were performed 20-25 days after the implantation. Then, animals were sacrificed and infected specimens were histopathologically examined. The sonographic examinations of the infected animals revealed lobulated, heterogeneous cystic intraabdominal masses. There were echogenic solid areas with hypoechoic and anechoic cystic areas within the lesions. Doppler ultrasound examination revealed vascular islands within those heterogeneous cystic lesions. Color mode showed multiple vascular coding areas within the solid part of the lesions, most of them were venous structures but there were also arterial vessels showing dominant flow with low resistive indices. Vascular structures were supposed to be the invaded native mesenteric vessels within the infiltrating inflammatory mass lesions. We consider that the Doppler ultrasound finding of irregular mesenteric vascular structures within intraabdominal heterogenous mass lesions may be an important sign for the diagnosis of experimental non-visceral alveolar echinococcosis in Meriones unguiculatus.

Idiopathic infantile arterial calcification: case report

Idiopathic infantile arterial calcificationI (IIAC) is a rare disorder characterized by calcium deposition in the internal elastica lamina of medium and large arteries and it has been defined in term of molecular genetics. It is usually fatal, approximately 85% of all patients die within the first months of life owing to ischemia of vital organs. Death from myocardial infarction usually occurs in the first 6 months. Calcification in a peripheral artery with electrocardiogram (ECG) changes of occlusive coronary artery disease suggests the diagnosis. It is caused by mutations in the ENPP1 gene localized on chromosome 6q22 and has OMIM number 208000. A case with fatal evolution at the end of the first month is presented.

Minimal-preparation abdomino-pelvic CT in frail and elderly patients: prognostic value of colonic and extracolonic findings

AIM

To examine the overall survival of patients who had had been referred for minimal preparation abdomino-pelvic computed tomography (MPCT), and to assess the prognostic value of the colonic and extracolonic findings detected.

METHODS AND MATERIALS

The survival of a cohort of 1029 elderly and frail patients, with clinical symptoms and signs suspicious for colorectal cancer (CRC), who had undergone MPCT between 1995 and 1998 was investigated. Univariate and multivariate survival analyses were undertaken according to the presence of CRC and extracolonic abnormalities (ECA).

RESULTS

The median age of the 1029 patients was 79.4 years. The overall median survival following MPCT was 5.4 years; and 6.6 years if no abnormality was detected. On multivariate analysis, age, sex, CRC status, and number of ECAs were significant factors in overall survival. Median survival for those with confirmed CRC [n=91 (prevalence, 8.8%)] was 1.1 years, compared with 5.9 years without CRC (p<0.0001); and 2.4 years for those with one or more ECA [n=245 (prevalence, 23.8%)], compared with 6.1 years without ECA (p<0.0001). Survival was progressively shorter for increasing numbers of ECAs; and shorter for previously unknown non-CRC malignancies (n=24) compared with CRC (p<0.0001).

CONCLUSIONS

MPCT appears to have prognostic potential in this patient population, with significant reductions in survival if a CRC or ECA is detected. The detection of ECA would appear to have at least as important an impact on the usefulness of the examination as the detection of CRC.

CT of pelvic extraperitoneal spaces: an anatomical study in cadavers

AIM

To evaluate the pelvic extraperitoneal compartments and communications with abdominal retroperitoneal spaces.

MATERIAL AND METHODS

Helical computed tomography (CT) was used to image the abdomen and pelvis after injection of 800 ml of dilute (1 in 25) contrast material into prevesical, perivesical and perirectal spaces in eight embalmed cadavers. Axial images and multiplanar reconstructions were reviewed to determine flow pathways.

RESULTS

The prevesical space was injected in four cadavers, the perivesical space in two and the perirectal in two. After the four prevesical space injections, communication was seen with the perivesical (four of four), perirectal (one of four) and abdominal extraperitoneal spaces (posterior pararenal space in all, anterior pararenal space in two of four, and perirenal space in three of four). After the two perivesical injections, communication was seen with the prevesical (two of two), perirectal (two of two) and abdominal extraperitoneal spaces (posterior pararenal in two of two, anterior pararenal in two of two, and perirenal space in two of two). After the two perirectal space injections, communication was seen with the prevesical (two of two), perivesical (one of two) and abdominal extraperitoneal spaces (posterior pararenal in two of two, anterior pararenal in two of two, and perirenal space in one of two).

CONCLUSION

The extraperitoneal spaces of the pelvis comprise three communicating compartments: the prevesical space, the perivesical space, and the perirectal space. The perirectal space, previously thought to be separate, communicates with the perivesical and the prevesical spaces. Intercommunication occurs both between the pelvic extraperitoneal spaces and with abdominal retroperitoneal spaces.

Osteomalacia and secondary hyperparathyroidism after kidney transplantation: Relationship to vitamin D deficiency

Secondary hyperparathyroidism is highly prevalent in patients with end-stage renal disease. After successful kidney transplantation, however, parathyroid glands gradually involute to normal size with subsequent normalization of intact parathyroid hormone (PTH), serum calcium, and phosphorous concentrations. This report describes a 48-year-old diabetic end-stage renal disease patient who underwent a successful cadaveric kidney transplant. Serum calcium and phosphorous concentrations normalized within 6 months. Three years later, he presented with complaints of proximal muscle weakness that was progressively worsening. Physical examination revealed temporal wasting and proximal muscle weakness. Detailed neurologic examination was unremarkable except for decreased vibratory sensation in both feet. Laboratory data showed stable allograft function (serum creatinine, 1.3 mg/dL), hypocalcemia, and hypophosphatemia with markedly elevated alkaline phosphatase level (726 IU/L) and intact PTH level (947 pg/mL). Further laboratory evaluation revealed poor nutritional status and severe deficiency of 25(OH)D (4.0 ng/mL). Past medical history included remote episodes of acute pancreatitis due to prior alcohol abuse. Computed tomography of the abdomen showed calcific atrophic pancreas, and steatorrhea was confirmed on stool studies. Decreased bone mineral density was noted by computed tomography bone density scan. Secondary hyperparathyroidism and osteomalacia had developed due to severe vitamin D deficiency, occurring as a result of previously unrecognized, minimally symptomatic pancreatic exocrine insufficiency. Treatment with vitamin D, calcium, and pancreatic enzyme replacement led to remarkable resolution of clinical symptoms and secondary hyperparathyroidism (intact PTH, 65 pg/mL after therapy) and resulted in significant improvement in bone mineralization. Factors associated with vitamin D deficiency in the chronic kidney disease and post-transplant patient population are reviewed.

[An emulsion based on 1-bromoperfluorooctane: X-ray contrast properties and mechanisms of X-ray contrasting]

It has been shown that the emulsion of a mixture of the perfluorocarbons 1-bromoperfluorooctane and perfluoro[1-(4-methylcyclohexyl)piperidine], stabilized by egg yolk phospholipids, makes it possible to contrast rapidly (beginning with the 10th minute) and for a long time (up to 5 days) the tissues of various organs, such as liver, spleen, adrenal glands, heart, and the peritoneal part of the aorta. The roentgenograms of rat organs in in vivo experiments were evaluated by computer-assisted morphodensitometry. The contrasting of organs at early terms of the circulation of emulsion in the body is related to a high concentration of 1-bromoperfluorooctane in the blood flow, and the contrasting at later terms is related to the accumulation of emulsion particles by cells of the reticuloendothelial system.

Symptomatic ascites in a patient with hypothyroidism of short duration

Symptomatic ascites as a presenting symptom of hypothyroidism is quite rare. In most of the case reports, patients with ascites requiring therapeutic abdominal paracentesis have long-standing hypothyroidism. We present a case of symptomatic ascites in a subject with hypothyroidism following radioiodine therapy for Graves disease. A 70-year-old African-American man presented with increasing weakness, shortness of breath, weight gain, constipation, and abdominal distention. Past history was significant for coronary artery disease, diabetes, hypertension and history of radioiodine therapy for Graves disease 9 months prior to the presentation. He was taking levothyroxine at 50 microg per day for 3 months prior to the presentation. Physical examination findings were significant for puffiness around the eyes, decreased breath sounds at the lung bases, and distended abdomen with free fluid, hung-up reflexes, and cold extremities. The thyroid-stimulating hormone level at the time was 64 with a free T4 less than 0.4 ng/dL. Analysis of the ascitic fluid revealed an exudative effusion with a serum to ascitic fluid albumin gradient of 1.2. The patient required therapeutic abdominal paracentesis twice, with 4 L each time, to relieve the symptoms. Work-up to rule out other causes did not reveal any other relevant abnormality. After initiation of thyroid hormone replacement, the patient responded very well and the ascites resolved within 2 months. We conclude that ascites associated with hypothyroidism is rare but must be recognized early, since thyroid replacement is the definitive therapy.

[Potentials of computed-tomography colonography with added investigations of the abdominal cavity and small pelvis in the diagnosis of diseases of the colon, assessment of dissemination of the pathological process]

The aim of the investigation was an assessment of potentials of computed-tomography colonography (CTC) in diagnosis of diseases of the colon. CTC was made in 125 patients. The investigation was performed after special preparation of the patients for purgation of the colon. The patient was in the supine and prone position. After introduction of room air in the colon the axial sections were laid from the diaphragm cupola to the pelvic floor. The obtained data were estimated and the reconstructions were fulfilled using special software. Pathological alterations or anatomical specific features of the colon were detected in 86 out of 125 cases (68.8%), in 26 of the cases (28.6%) a conclusion was made of malignant tumors in the colon according to the data of CTC. The data obtained by CTC were compared with the data of fibrocolonoscopy, rectomanoscopy, irrigoscopy and histological investigation. In most cases the coincidence of the findings was noted.

The wandering spleen: CT findings and possible pitfalls in diagnosis

AIM

To report the CT features of wandering spleen, a rare condition which can be incidentally detected as an abdominal or pelvic mass or can present with torsion, causing an acute abdomen.

MATERIALS AND METHODS

The CT studies of seven patients, two children and five adults, with wandering spleen were reviewed. CT was performed urgently in three patients for acute abdomen, and electively in four.

RESULTS

CT findings of wandering spleen included absence of the spleen in its normal position and a mass located elsewhere in the abdomen or pelvis, i.e. an ectopic spleen, enhancing homogeneously in four cases and failing partially or completely to enhance in the other three, indicating infarction. A "whirl" appearance representing the twisted splenic pedicle was seen in the three cases with torsion. Urgent splenectomy confirmed infarction secondary to torsion.

CONCLUSION

The possible diagnosis of wandering spleen should be kept in mind when CT shows the spleen to be absent from its usual position and a mass is found elsewhere in the abdomen or pelvis. When, in addition, a "whirl" or partial or no enhancement of this mass are seen in a case presenting with acute abdomen, torsion of a wandering spleen is a likely diagnosis.