[Obstructive jaundice in proximal pancreatitis after sclerosing of a bleeding duodenal ulcer]

Two weeks after successful endoscopic sclerotherapy of a bleeding duodenal ulcer a fifty-year old male patient developed a benign enlargement of the head of the pancreas and obstructive jaundice. He underwent exploratory laparotomy with choledocho-jejunostomy because there was no evidence of malignant disease. The enlargement of the head of the pancreas and obstructive jaundice are considered to be symptoms of a pancreatitis as a complication of the endoscopic sclerotherapy.

The endoscopic Doppler: its value in evaluating gastroduodenal ulcers after hemorrhage and as an instrument of control of endoscopic injection therapy

In this prospective study of 80 patients with active bleeding from the gastrointestinal tract a Doppler ultrasonographic investigation of the gastroduodenal ulcers was performed, in addition to immediate endoscopic examination. Admitted to this study were ulcers with the stigmata of acute bleeding, such as a visible blood vessel in the ulcer floor, a blood clot, or a black base and Forrest III lesions. In 52 patients Doppler ultrasonography was able to document unequivocally a superficial blood vessel. Complete agreement of endoscopic and Doppler results was obtained in only 49% of the cases. When a blood vessel was positively identified, local injection of epinephrine and polidocanol was carried out. Thereupon, in the further course, the acoustic signal was shifted into deeper regions or disappeared entirely. In 8% of the cases initial sclerosing was followed by a rebleed, which was again treated by injection therapy. None of the patients died of their GI hemorrhage. Endoscopic Doppler ultrasonography is a new and effective procedure that enables objectification of the endoscopic findings. It identifies the indication for proceeding to operative endoscopy and can monitor the effectiveness of the latter.

Complete duodenogastric reflux: a scintigraphic sign of significant duodenal pathology

Complete reflux of duodenal contents into the stomach with persistent retention on hepatobiliary scintigraphy or radionuclide gastrointestinal bleeding studies is a relatively rare occurrence. Two cases of complete duodenogastric reflux are reported: one case in a patient with a perforated duodenal diverticulum and the other in a patient with an inflamed, bleeding duodenal ulcer. The finding of complete duodenogastric reflux and persistent retention in the stomach should instigate a thorough evaluation for significant duodenal pathology.

[Arteriography in digestive hemorrhage]

As it appears from a review of the literature of the last decade, arteriography is important in the diagnosis and management of gastrointestinal haemorrhage but its role has to be evaluated by a multidisciplinary approach. In fact, the role of arteriography in upper gastrointestinal bleeding is often therapeutic, because diagnosis is often made by endoscopy. In lower gastrointestinal bleeding, arteriography is mainly diagnostic and its role in treatment remains limited. Controlled studies are necessary to compare transcatheter embolization with other treatments.

Intramural hemorrhage simulating gastric neoplasm

We report a case of benign gastric ulcer with secondary extensive intramural hemorrhage causing a radiographic appearance consistent with a large ulcerated gastric neoplasm. This is the second such case reported and the first studied with sonography and computed tomographic scan. A brief review of the literature on intramural gastric hematoma is presented.

Evaluation of technetium-99m DTPA for localization of site of acute upper gastrointestinal bleeding

Intravenous Tc-99m DTPA was evaluated in 34 patients with active upper gastrointestinal bleeding. Active bleeding was detected in 25 patients: nine in the stomach, 12 in the duodenum, and four from esophageal varices. No active bleeding was seen in nine patients (two gastric ulcers and seven duodenal ulcers). Results were correlated with endoscopic and/or surgical findings. All completely correlated except: 1) one case of esophageal varices in which there was disagreement on the site, 2) three cases of duodenal ulcers that were not bleeding on endoscopy but showed mild oozing on delayed images and 3) one case of gastric ulcer, in which no bleeding was detected in the Tc-99m DTPA study, but was found to be bleeding at surgery 24 hours later. The Tc-99m DTPA study is a reliable method for localization of upper gastrointestinal bleeding with an agreement ratio of 85%. This method also can be used safely for follow-up of patients with intermittent bleeding. It is less invasive than endoscopy, is easily repeatable, and has the same accuracy.

An experimental model for the detection and localisation of gastrointestinal bleeding using 99mTc-DTPA

99mTc-DTPA was successfully used to detect simultaneously gastrointestinal bleeding sites in experimentally created mucosal ulcers in the colon and stomach of rabbits. Unlike the other radiopharmaceuticals that are currently used, 99mTc-DTPA was rapidly cleared from the vascular, hepatic and splenic circulation. The overall background radioactivity was low. 99mTc-DTPA appears to be an ideal agent for detection and localisation of gastrointestinal bleeding sites.

[Use of vasopressin in the treatment of acute hemorrhagic lesions of the stomach. Our experience]

Since bleeding from acute lesions of the gastric mucosa can cease spontaneously and the mortality rate of emergency surgery is high, conservative treatment is always preferable. Satisfactory results were obtained with continuous infusions of vasopressin in low doses (0.2 U/kg/hr for 8 hours) so that this treatment appears a valid alternative to more recent techniques (somatostatin).

Image subtraction in acute gastrointestinal bleeding studies using 99Tcm-DTPA

99Tcm-DTPA has been evaluated in our clinical and experimental programme for the detection of acute gastrointestinal bleeding. As an adjunct to this programme, a protocol for image subtraction has been developed. The patient remains still while sequential static images I(i) (i = 1, . . ., N) are taken. They are first normalized to equal total counts and then subtracted images are produced according to the following three methods (a) I(i + 1)-I(i) (b) I(i) - I(mask) (c) I(mask) - I(i) where i not equal to mask and I(mask) denotes a user-selected mask image. Method (a) demonstrates fresh bleeding and sequential movement of blood in the bowel. Methods (b) and (c) demonstrate overall migration of blood and accumulated bleeding depending on the choice of the mask image.

Abdominal scintigraphy with 99Tcm-labelled red cells in the detection of rebleeding from peptic ulcers

The technique of 99Tcm-labelled red cell scintigraphy as a means of detecting rebleeding was investigated in 33 patients with bleeding peptic ulcers. Scintigrams were performed twice during the 24 h period succeeding diagnostic endoscopy. There was scintigraphic evidence of rebleeding in 23 patients but this was clinically manifest in 14 patients only. Thirteen of the 14 patients with clinical rebleeding had positive scintigrams while only in one patient with clinical rebleeding was the scintigram negative (P less than 0.05). These results show that rebleeding is common and often clinically inapparent during the first 24 h following gastroscopy but that in the absence of scintigraphic rebleeding serious clinical rebleeding is unlikely to occur.

The intestinal tract

In this chapter, we have considered angiographic applications for diagnosis and management of patients with gastrointestinal bleeding and intestinal ischaemia. For patients with upper gastrointestinal bleeding, diagnostic angiography should be performed only when and if endoscopy is not available or non-contributory. For therapeutic purposes, angiography is applied in patients who continue to bleed despite conservative measures and intervention becomes unavoidable. Therapeutic interventions include the intra-arterial infusion of vasopressin and/or transcatheter embolization. In patients with rectal bleeding the addition of radionuclide studies has reduced the number of negative arteriographic examinations. We currently use the radionuclide studies only as a guide to whether active bleeding is present or not. If the radionuclide test is negative, we do not perform angiography. If it is positive we proceed with angiography in order to confirm localization and control bleeding with an intervention. For patients with rapid bleeding who are haemodynamically unstable we bypass nuclear medicine and proceed directly with angiography. In patients with suspected intestinal ischaemia, angiography is the only means of deciding whether ischaemia is of the occlusive or the non-occlusive form. Mesenteric vascular occlusions are treated surgically while low flow states are managed with mesenteric artery infusions of papaverine. Angioplasty has been and can be applied in patients with mesenteric arterial stenoses and symptoms of chronic intestinal ischaemia.

Scintigraphic detection of acute gastrointestinal bleeding using 99Tcm-DTPA

Technetium-99m DTPA is a good agent for detecting sites of acute gastrointestinal bleeding due to its rapid clearance by the kidneys and its stability in the bowel achieving a good target to nontarget ratio. It has been successfully tried for a pilot study. Further evaluation is in progress for its sensitivity. In cases where there is a slow rate of bleeding, we are currently evaluating injection of the dose by infusion, slowly over 15 min instead of the rapid i.v. injection.

Radiologic investigation of peptic ulcer disease

Fiberoptic endoscopy has uncovered some of the weaknesses with the traditional upper gastrointestinal series and has prompted more critical evaluation of the radiographic examination of the stomach. The biphasic examination using gas distention as well as thick and thin barium suspensions incorporates the best features of both single- and double-contrast examinations. The radiologist needs to be aware of the different signs of ulcer disease as demonstrated by the two different types of examinations, and attention to technical details is critical if thick barium coating is really going to produce striking anatomic detail. Knowing the radiographic features of the common and uncommon manifestations of peptic ulcer disease is important for the radiologist performing gastrointestinal studies. By performing technically excellent studies and by recognizing the various manifestations of peptic ulcer disease, the radiologist will continue to play an important role in diagnosing suspected or known peptic ulcer disease.

[Preoperative diagnosis of a Meckel's diverticulum (author's transl)]

The most common complications of a Meckel's diverticulum is bleeding. With the introduction of abdominal scintigraphy we have a non-invasive examination method at our disposal which enables this condition to be diagnosed with accuracy preoperatively. A relevant case is described.

Occult gastric bleeding demonstrated by bone scan and Tc-99m-DTPA renal scan

A patient is described who had coagulopathy and clinically intermittent gastrointestinal bleeding. The bleeding site was clearly shown on renal and bone imaging performed at a time when the patient was considered clinically to have stopped bleeding. A bleeding gastric ulcer was subsequently demonstrated by radionuclide and contrast angiography, and at surgery.

Bleeding peptic ulcer caused by ectopic gastric mucosa in a duplicated segment of jejunum

The authors present a case in which a patient suffered a bleeding jejunal ulcer caused by heterotopic gastric mucosa in a congenital duplication of a segment of jejunum. This is the first case diagnosed preoperatively by two different radiographic means. These lesions were shown by both pertechnetate flow and barium small bowel studies. The rarity of these entities and the modalities used for diagnosis are described.