Diagnosis of Budd-Chiari syndrome: comparison between sonography and MR angiography

PURPOSE

To compare findings with color Doppler sonography and magnetic resonance (MR) angiography in the diagnosis of Budd-Chiari syndrome.

MATERIALS AND METHODS

Doppler sonographic scans and MR angiograms in 11 patients (five men and six women; age range, 30-63 years; mean age, 45 years) with proved Budd-Chiari syndrome were subjected to retrospective review.

RESULTS

Occlusion of three hepatic veins was identified in each of two patients, of two hepatic veins in each of four patients, and of one hepatic vein in each of five patients at both Doppler sonography and MR angiography. Dominant intrahepatic venovenous collateral pathways were identified in eight of 11 patients and spider-web collaterals were identified in three of 11 patients at both sonography and MR angiography.

CONCLUSION

Sonography enables noninvasive diagnosis of Budd-Chiari syndrome. MR angiography affords similar diagnostic information and may be of value when the diagnosis is not clear after sonographic examination or when body habitus limits a complete sonographic examination.

Omeprazole treatment of children with peptic esophagitis refractory to ranitidine therapy

OBJECTIVE

To evaluate the cause of chronic abdominal pain lasting more than 3 weeks in 153 patients aged 6 to 18 years (mean, 9.9 years) who had undergone endoscopy.

DESIGN

Those patients with peptic esophagitis as the cause of their chronic pain were treated with high-dose ranitidine hydrochloride, followed by the proton-pump inhibitor, omeprazole, for those who did not respond to a histamine2-receptor antagonist.

RESULTS

Eighty-four percent of patients had peptic esophagitis, 3% had Helicobacater pylori gastritis, and 3% had ulcer disease. Seventy percent of the patients with peptic esophagitis responded to an 8-week course of high-dose ranitidine hydrochloride (4 mg/kg per dose, twice a day or three times a day). Of the 30% of patients who failed to respond to ranitidine therapy, 87% responded to an 8-week course of omeprazole (20 mg/d). The grade of esophagitis at initial endoscopy was a predictive factor for response to ranitidine therapy. Ninety percent of patients with grade 1 esophagitis responded to ranitidine therapy vs only 43% of those with grade 3 or 4 esophagitis. Only five patients (4%) failed to respond to both therapies; three of these subsequently underwent Nissen fundoplications. There were no side effects of either ranitidine or omeprazole therapy.

CONCLUSIONS

These findings indicate that (1) peptic esophagitis was a common cause of chronic abdominal pain in pediatric patients and (2) omeprazole was effective in the treatment of esophagitis in children and adolescents that was resistant to high-dose histamine2-receptor antagonists.

Isolation and characterization of a sea urchin zygote cortex that supports in vitro contraction and reactivation of furrowing

The isolation of the cortex of the sea urchin blastomere by detergent lysis was explored with the aim of analyzing components important in the structure and function of the cortical cytoskeleton, and their relationship to such phenomena as contraction. Buffered EGTA medium supplemented with isotonic glycerol and with magnesium, at a level close to the reported internal cellular concentration, yields stable cytoskeletal cortices that retain their spherical shape. Cortices prepared this way contain actin, myosin, fascin and spectrin, components normally associated with the cortical cytoskeleton in a similar distribution to that in intact zygotes. They retain the organized cortical filamentous structure, including the actin-fascin bundles that form cores of microvilli. ATP and NaCl caused changes in cortical shape, described as either contraction or expansion, respectively. Spectrin, but not myosin, was partially extracted by NaCl, resulting in expansion of the cortex that suggests a role for spectrin in maintenance of cortical structure. ATP (but not ADP nor ATP gamma S), which caused the partial removal of myosin and spectrin, led to the contraction of the cortex, consistent with a role for myosin in cortical tension. In cortices isolated from dividing eggs, the zygotes retained their cleavage furrows and ATP induced continuation of furrow progression. This preparation appears to be a useful in vitro model for cytokinesis.

Intraoperative ultrasound imaging of the liver at the time of colorectal cancer resection

OBJECTIVES

To evaluate the accuracy of intraoperative ultrasound (IOUS) liver imaging at the time of primary colorectal cancer resection, which might eliminate incurable patients from adjuvant chemotherapy trials or permit earlier resection of curable metastases.

DESIGN

A prospective trial of routine IOUS liver imaging during resections of primary colorectal cancer. The rate of detection of occult metastases by IOUS imaging alone and the false-negative rate over 22.7 months of follow-up were determined.

SETTING

A tertiary care referral center in Boston, Mass.

PATIENTS

Fifty-five patients undergoing 56 operations for colorectal carcinoma between May 1990 and June 1992.

MAIN OUTCOME MEASURES

The rate of detection, by IOUS imaging alone, of otherwise occult hepatic metastases, the total number of patients with metastases detected at any time during follow-up, and the rate of false-negative findings on IOUS imaging and direct examination.

RESULTS

Occult hepatic metastases were detected by IOUS imaging alone in 5% of patients. Restriction of IOUS imaging to patients with T3 or T4 lesions or recurrent cancers would have identified all metastases and increased the detection rate to 10%. Occult metastases were detected by IOUS imaging alone in 12.5% of patients with T3, N0 lesions. The rate of false-negative findings on IOUS imaging was 13% overall, 0% for patients with T1 or T2 lesions, 3% for patients with node-negative findings, and 7% for patients with T3, N0 lesions.

CONCLUSIONS

The small increment in the detection of occult metastases by IOUS liver imaging does not warrant its use in all patients with colorectal cancer. Selective use in patients with T3 or T4 lesions or recurrent cancers increased the incremental gain in detection. The observed frequency of occult metastases in patients with T3, N0 lesions is sufficient to impact on results of adjuvant chemotherapy trials. Longer follow-up in more patients is needed to determine whether a negative IOUS study is an additional favorable prognosticator in patients with T1 and T2 lesions and node-negative findings.

The relationship of prostate-specific antigen to digital rectal examination and transrectal ultrasonography. Findings of the American Cancer Society National Prostate Cancer Detection Project

The participating institutions of the American Cancer Society National Prostate Cancer Detection Project did 520 biopsies on 2425 men over a 3.5-year period. A total of 88 cancers were confirmed pathologically, 93% of which clinically were organ confined. In 324 men (62.3%), a recommendation for biopsy was made based solely on the results of transrectal ultrasonography (TRUS); in 69 patients (13.3%), solely on the digital rectal examination (DRE); in 116 patients (22.3%), on abnormal DRE and TRUS examinations; and in 11 patients (2.1%), in whom DRE and TRUS were normal, on elevated prostate-specific antigen (PSA) levels. The TRUS was abnormal in 80.6% of men found to have cancer, and the PSA level and DRE were abnormal for 67% and 50% of cancers, respectively. The influence of PSA level on cancer detection increased as the serum level increased above 4 ng/ml. The positive predictive values of both the DRE and TRUS were influenced significantly by the presence of an elevated PSA level (P = 0.044 and P less than 0.001, respectively). The results of this ongoing multicenter study support the following statements: (1) the prostate cancer detection rate is influenced by this diagnostic triad and (2) the detection rate of organ-confined disease can be improved substantially by early detection programs.

Experimental and clinical observations on hepatic cryosurgery for colorectal metastases

Cryosurgery, using liquid nitrogen at -196 degrees C, was explored for treating colorectal liver metastases in an experimental study of rat colon cancer and in a clinical investigation of patients with unresectable liver tumors. The viability of rat colon cancer isografts showed that while two or three freeze-thaw cycles were 100% effective in controlling established isografts and preventing isograft take, one freeze-thaw cycle was suboptimal. In these animals cryosurgery was as effective as surgical resection in controlling established experimental liver metastases. Cryosurgery by operative liver exposure and intraoperative ultrasound monitoring were used to treat liver metastases from colorectal cancer in 24 patients. At a median follow-up of 2 years (range, 5 months to 5 years), seven patients (29%) are disease free, eight (33.5%) are alive with recurrent tumors, and nine (37.5%) have died. The patterns of failure were: remaining liver and extrahepatic sites, ten patients (59%); remaining liver only, six patients (35%); and extrahepatic only, one patient (6%). These data demonstrate that cryosurgery is a useful modality for treating unresectable primary and metastatic liver cancers. Addition of systemic adjuvant therapy may improve the tertiary failure following the control of liver metastases.

A 5-year study of cryosurgery in the treatment of liver tumors

This report summarizes our 5-year experience with cryosurgery for in situ ablation of liver tumors. The liver was exposed with laparotomy, and the tumors were subjected to two freeze-thaw cycles using liquid nitrogen delivered by insulated probes; cryoablation was monitored with intraoperative ultrasonography. Tumor markers and computed tomography evaluated tumor response during long-term follow-up. From 1985 to 1990, 32 patients (19 men and 13 women) were entered into this study. The histologic characteristics of the tumors were as follows: colorectal, 24 patients; hepatoma, three patients; neuroendocrine, two patients; and others, three patients. After a follow-up period of 5 to 60 months (median follow-up, 24 months), nine patients (28%) remained disease free, 11 patients (34%) were alive with disease, and 12 patients (38%) died. The patterns of failure included liver and extrahepatic disease in 54% of cases, liver disease only in 32% of cases, and extrahepatic disease only in 14% of cases. In patients with "liver only" failure, recurrence at the treatment site occurred in three patients (9%). This study establishes the long-term effectiveness of cryosurgery in the treatment of primary and metastatic liver tumors.

The blood pressure and heart rate chronome of centenarians

Rhythm characteristics of blood pressure (BP) and heart rate (Hr) of 11 healthy centenarians and 66 medical students are described. Each subject ambulatorily monitored measured BP and HR around the clock at 15-min intervals for 48 hours. Least-squares spectra were obtained by the fit of cosine curves (cosinor) and compared between the two populations. Confounding by geographic differences seems to be ruled out by comparisons with results from international data bases. A shift in prominence from the circadian domain to higher frequency harmonics was found for the BP but not for the HR of centenarians. In clinically mostly healthy centenarians, markers of primary aging may consist of a relatively low circadian BP and HR amplitude and a tendency toward internal and external desynchronization. Whether these chronobiologic changes with age are desirable, indifferent or undesirable can now be elucidated by outcome studies, in the light of the reference standards provided herein.

Effect of cyclosporine and steroids on canine bile flow

Cyclosporine and hydrocortisone are the main immunosuppressants used in transplant surgery. The purpose of this study was to determine the effect of intravenous administration of cyclosporine and hydrocortisone on bile flow in dogs. Cyclosporine in doses of 0.5, 1.0 and 1.5 mg.kg-1.hr-1 were administered along with 18 mumol/min intravenous sodium taurocholate to dogs with chronic biliary and gastric fistulas. Bile volume and bile chloride concentration and output were increased by cyclosporine in a dose-related manner, whereas bile salt concentration decreased and bile salt output was unchanged. Hydrocortisone produced small but significant increases in bile flow only at the highest dose of hydrocortisone administered. Subsequently, experiments were performed when sodium taurocholate was administered in progressively increasing doses (9, 18 and 36 mumol/min), with the dose changed every hour. Bile volume, [14C]erythritol clearance in bile and bile salt concentrations were measured with and without cyclosporine and hydrocortisone administration. Cyclosporine increased the bile salt-independent fraction of canalicular bile flow and ductular bile flow. Experiments evaluating the role of the cyclosporine carrier polyoxyethylated castor oil (Cremophor EL) demonstrated that this substance had no independent choleretic activity, whereas cyclosporine dissolved in ethanol and administered without Cremophor EL significantly increased bile flow. The results of this study indicate that cyclosporine stimulates chloride-rich choleresis independent of bile salt secretion.

Ankle tendons: evaluation with CT

Computed tomographic (CT) analysis of 21 clinically suspected ankle tendon injuries was performed in 18 patients. In six of the 21 ankles surgical exploration was done, and in one ankle evaluation was done while the patient was under anesthesia. In all seven cases the CT findings were confirmed and in three the clinical diagnosis was disproved. CT provided additional information and helped guide treatment in the majority of patients studied. Thus CT is an accurate, noninvasive modality for assessing ankle tendon injuries.