Perforation of the abdominal segment of the esophagus

Five patients with perforation of the abdominal segment of the esophagus are described. In two patients with tear of the abdominal segment alone, perforation occurred into the retroperitoneal space. In the other three, there was a tear that extended above the diaphragm, and perforation was into both the thorax and lesser sac in one and into both the thorax and retroperitoneal space in the other two. The clinical manifestations and treatment of these patients differ from those of the more common intrathoracic perforation.

Malignant tumors of the small bowel

The four common types of small bowel malignancies have different clinical presentations, routes of metastatic spread, and prognoses, and may require selective treatment. A review of our experience over a 16-year period revealed 45 cases: 16 adenocarcinomas, 13 carcinoids, nine leiomyosarcomas, five lymphomas, and two fibrosarcomas. Adenocarcinomas tend to occur in the upper part of the small intestine, cause obstruction and occult blood loss, and metastasize to the regional nodes and liver. Carcinoids generally begin in the distal portion of the small bowel, may form rather large metastatic masses and cause obstruction from a metastatic mass or intussusception, and are often multiple. Leiomyosarcomas develop in any part of the bowel, may present a primary mass, gross hemorrhage, or perforation, and have blood-borne metastases. Lymphomas tend to occur in the distal part of the small bowel, with pain or mass formation, and spread via the lymphatics. Critical analysis of the clinical presentation and findings should allow preoperative recognition of the specific pathologic type.

Compulsive ingestion of foreign bodies in a schizophrenic patient

We have described a rare case of compulsive ingestion of foreign bodies in a schizophrenic woman. From this experience, we have proposed some guidelines that may be useful in managing similar clinical problems.

Esophageal involvement in epidermolysis bullosa dystrophica

The clinical and radiographic findings in four cases of epidermolysis bullosa dystrophica of the esophagus are presented. The patients were 5-67 years old. All had typical skin lesions and dysphagia. The most impressive radiographic finding was bulla formation in virtually any part of the esophagus. The bullae would resolve or ulcerate. Scar formation with resultant stricture of the esophagus was a common sequela of this disease.

Arteriography with simultaneous gastric distention to detect insulin-secreting tumors of the pancreas

Gaseous distention of the stomach at the time of arteriography enhances the contrast of densities within the pancreatic parenchyma, resulting in excellent visualization and therefore precise preoperative localization of insulin-secreting tumors of the pancreas. This relatively simple modification of selective arteriography was used in the last three consecutive patients we have seen with insulinomas. Apparently, the presence of air in the stomach makes the "tumor blush" that results from the uptake of the contrast dye by the vessels within the insulinoma and is clearer than in selective arteriography alone. The stomach was distended at the time of selective arteriography with carbonated soft drinks in two cases and by gas-producing pills in one. In all three cases, the location of the tumor shown by arteriography coincided exactly with the operative findings. Distal pancreatectomy was required in two; enucleation of the insulinoma was possible in one. All three patients recovered from operation uneventfully and were completely relieved of symptoms.

Neurogenic tumors of the duodenum in patients with neurofibromatosis

Neurogenic tumors of the duodenum may occur in patients with neurofibromatosis. They may be solitary or multiple and are located distal to the duodenal bulb. The presenting complaints may be hematemesis, vomiting, or jaundice. The lesions are generally benign and have a low potential for malignant degeneration. Four cases are reported.

Reticular mosaic (urticarial) pattern of the colonic mucosa in Yersinia colitis

The colonic mucosa of a patient with Yersinia colitis exhibited a reticular mosaic pattern on an air-contrast barium enema. The authors conclude that Yersinia colitis can be added to the list of colonic lesions producing this characteristic pattern.

Perforation of the colon above the peritoneal reflection during the barium-enema examination

Four cases of perforation of the colon above the peritoneal reflection during a barium-enema examination were reviewed with regard to the type of examination, site of perforation, status of the colon, clinical manifestations, mode of detection, and consequences. Perforation above the peritoneal reflection does not seem to be directly related to technical factors. The cecum and ascending colon, with their larger lumina, are the most likely sites. Because such patients are usually asymptomatic at the time, careful examination of post-fluoroscopic radiographs for signs of perforation is strongly recommended.

Diagnostic and interventional angiography in acute gastrointestinal hemorrhage

The use of vasopressin infusion or arterial embolization in the treatment of 87 patients with gastrointestinal hemorrhage is reviewed. A bleeding point was identified angiographically in 46 patients (53%), with a higher success rate in those with upper gastrointestinal hemorrhage (63%) than in those with lower (39%) gastrointestinal hemorrhage. Vasopressin infusion in 33 patients completely stopped hemorrhage in 14 and slowed hemorrhage pending surgery in another 5. Gelfoam embolization was successful as definitive therapy in 12 of 15 patients. Mortality as a result of hemorrhage or its sequelae was 40% in patients with upper gastrointestinal hemorrhage and 21% in those with lower gastrointestinal hemorrhage.

Lower gastrointestinal tract dysfunction in patients receiving long-term hemodialysis

Severe bowel dysfunction developed in 25 of 945 patients receiving long-term hemodialysis during a ten-year period. Colonic perforation occurred in 12 patients, six of whom died due to peritonitis. In seven instances, the perforation occurred spontaneously. Ten other individuals exhibited prolonged, severe adynamic ileus that progressed to colonic pseudo-obstruction in eight patients. Medical decompression (eight patients) and surgical bowel decompression (two patients) resulted in recovery in nine. Aluminum hydroxide gel, which was taken regularly by all patients, was associated with notable chronic constipation prior to the occurrence of bowel perforation or protracted adynamic ileus in 78% of these individuals.

Long term effects of arterialization of the portal vein stump in dogs with Eck's fistula

This study investigates the possibility of avoiding the sequelae of Eck's fistula in dogs by preserving the hepatic blood flow with an autologous vein graft inserted between the infrarenal aorta and the transected stump of the portal vein as its entrance into the liver. Ten dogs with such experimental preparation were observed for signs of encephalopathy; the patency of the grafts was assessed by periodic arteriograms. The signs of encephalopathy and general deterioration usually observed in dogs with Eck's fistula were prevented; however, marked dilation of the intrahepatic branches of the portal vein leading sometimes to spontaneous rupture of the liver or to thrombosis of the venous graft was observed. Thus, this technique does not appear to be a satisfactory long term solution for preventing the deleterious effects of Eck's fistula in dogs.

Plain film findings of hydropneumoperitoneum

Abdominal radiographs of 11 patients with hydropneumoperitoneum were reviewed. The centrally located air collection was noted in nine of the 11 patients. In the other two patients with a large amount of fluid in the pelvis, the air bubble was located in the upper abdomen. In two patients, the edge of the centrally located large air bubble was ringed by a number of small bubbles. The falciform ligament was demonstrated in five. Air-fluid levels were seen in the upper abdomen in six patients in whom upright films of the abdomen were obtained. Hydropneumoperitoneum should be suspected in supine abdominal radiographs when one recognizes a large air collection with or without surrounding small air bubbles.

Variation in falciform ligament with pheumoperitoneum

The anatomic variation in length, thickness and course of the falciform ligament was studied on abdominal radiographs of 21 patients with pneumoperitoneum. In adults, considerable variation was found: the length ranged from 6 to 14 cm (mean 9.9 cm) and thickness from 1 to 11 mm (mean 6mm). In contrast, children displayed a uniformly thin ligament. Familiarity with anatomic variation of the falciform ligament aids prompt recognition of pneumoperitoneum in seriously ill patients.

Bezoar of the esophagus

An esophageal bezoar occurring in a young patient without esophageal abnormality is described. The history of severe progressive dysphagia following forceful vomiting and presence of a gastric ulcer suggest that the esophageal bezoar might have originated in the stomach.

How and when to use barium for diagnosis of small bowel obstruction

The diagnosis of intestinal obstruction is readily made when a patient presents with typical history and signs, and when plain films of the abdomen display characteristic findings. Some patients, however, constitute diagnostic problems because abdominal roentgenograms are still equivocal, even after repetition in four hours. In the unclear case, use of a barium meal will safely, promptly, and routinely prove or disprove small bowel obstruction. Intestinal obstruction in which the initial abdominal films tend to be either unrevealing or equivocal include high obstructions, including the superior mesenteric artery syndrome; presence of strangulation; partial small bowel obstruction; and fluid-filled proximal bowel. In intestinal obstruction, characteristic roentgenographic findings with use of barium meal are normal to rather rapid transit time to the point of obstruction; homogenous dilution of barium in dilated proximal loops; and inhomogenous, scattered, and fragmented collections of barium in the distal, collapsed loops.

Intestinal atony in progressive systemic sclerosis (Scleroderma)

A 27-year-old woman with a long history of scleroderma developed megacolon and severe fecal vomiting as a result of intestinal atony. Evacuation of fecal impaction with water-soluble contrast enema resulted in prompt relief of fecal vomiting and gradual return of bowel function.

Intramural hematoma (incomplete perforation) of the esophagus associated with esophageal dilatation

Five cases of intramural hematoma of the esophagus complicating esophageal dilatation are presented along with a review of the literature. In all 5 patients, this complication developed during dilatation for benign stricture. The esophagram in each patient demonstrated double columns of contrast material separated by a radiolucent stripe, characteristic of incomplete tear of the esophagus. All 5 responded to conservative management without complication.

Circumferential web of the upper esophagus

Two patients with circumferential webs of the upper esophagus are presented. Both patients had a long history of intermittent dysphagia, particularly with solid food. The clinical, endoscopic, and radiologic features of these webs are discussed.

New technique for pelvic venography during ascending phlebography

A technique of pelvic venography making it possible to obtain satisfactory opacification of the iliofemoral segment of the pelvic veins consistently during ascending phlebography is described. The main features are the compression of the inferior vena cava with a compression band and balloon, and the use of a large amount of contrast material.