["Uncompensated" small bowel obstruction in adults. Ultrasonographic findings of free fluid between loops and its prognostic value]

Plain abdominal film is the method of choice in the assessment of intestinal obstruction. This technique exhibits some limitations and must be frequently correlated with other diagnostic tools. Of them, US has been recently reported to allow the morphofunctional study of intestinal loops with high accuracy. Nevertheless, the literature on the usefulness of US disregards a sign of great interest, i.e., extraluminal fluid between bowel loops. Our personal experience in 56 adult patients with surgically confirmed small bowel obstruction suggests that this findings, demonstrated by US in 43 patients (73%), identifies early intestinal wall damage with high sensitivity. US, depicting fluid between bowel loops, can distinguish the various stages of obstruction, with major consequences on clinical management. US and plain abdominal film findings allowed us to distinguish three stages of obstruction: simple obstruction (15/56 patients, 27%), uncompensated obstruction (26/56 patients, 46%), and complicated obstruction (15/56 patients, 27%). These three evolutive stages exhibit different severity and require different surgical approaches.

Ultrasound-guided aspiration in suspected sepsis of resection arthroplasty of the hip joint

The authors described 17 patients who had had resection arthroplasty of the hip and who were suspected of having an infection. The resection arthroplasties had been performed for previous infection. All the patients were studied by ultrasonography to detect effusion in the pseudoarticular space. Thirteen of the 17 patients were found to have an effusion by ultrasonography. Fluid was obtained in 9 of the 13 patients by ultrasonographic-guided aspiration. The mean aspirated volume was 3 ml (range 1-25 ml). Five of the 9 aspirates proved to be septic. The echopattern in all but one of those five with sepsis was nonechofree. Of four other patients in whom it was not possible to aspirate fluid lavage of the pseudoarticular space one yielded a positive culture. The role of ultrasonography in the diagnosis and management of patients who have undergone resection arthroplasty of the hip and who are suspected of having an infected pseudoarticular space is discussed.

Detection of radiographically occult ankle fractures following acute trauma: positive predictive value of an ankle effusion

OBJECTIVE

The purpose of our study was to determine if the presence of an ankle effusion on plain radiographs after acute ankle trauma is predictive of occult ankle fracture when no fracture is visible on the standard radiographic series.

SUBJECTS AND METHODS

The ankle radiographs of 1153 patients with acute ankle trauma were examined for fracture and for the presence and extent of anterior and posterior capsular distension. Patients with ankle effusions but no detectable fracture subsequently underwent sagittal and coronal complex-motion tomography.

RESULTS

Eleven of 33 patients with ankle effusions and otherwise normal plain radiographs had occult fractures identified with tomography. The fracture sites were as follows: osteochondral fracture of talar dome (n = 4), neck of talus (n = 1), medial malleolus (n = 1), anterior tibial rim (n = 1), posterior tibial rim (n = 1), tibial plafond (n = 1), lateral malleolus (n = 1), and anterior process of calcaneus (n = 1). The radiographic size of an ankle effusion was predictive of occult fracture. An ankle effusion measuring 13 mm or more in anterior plus posterior capsular distension had an 82% sensitivity and 91% specificity for underlying fracture in our series. The positive predictive value of an ankle effusion 13 mm or greater was 82%.

CONCLUSION

The presence of an ankle effusion on plain radiographs following acute ankle trauma is suggestive of an underlying fracture. An ankle effusion of 13 mm or greater in total capsular distension has a positive predictive value of 82% for occult fracture and is a reasonable threshold to prompt additional imaging.

Malignant joint effusions secondary to solid tumor metastasis

We describe the case of a patient with breast cancer who developed bilateral malignant knee effusions, and review the English language literature. Patients with solid tumors who develop malignant joint effusions are rare; 27 cases have been reported (including our patient). The knee is the predominant site of joint involvement (p < 0.001). Synovial fluid (SF) analysis often demonstrates noninflammatory bloody effusion. Synovial biopsy was positive in 11 of 16 cases in which it was performed. SF cytology was positive in one half of cases in which it was obtained. Arthritis secondary to metastasis is a poor prognostic finding. A strong clinical suspicion is necessary to make the diagnosis; SF cytology or synovial biopsy can confirm it.

The incidence and significance of acute post-hysterectomy pelvic collections

In a prospective study, 32 consecutive patients underwent endovaginal pelvic scanning in the first post-operative week following hysterectomy. Twenty-four attended for a further scan at clinical follow up. Vaginal vault fluid collections were identified in 19 women (59%) on the first post-operative scan. Fifteen of the 19 with collections had no significant pyrexia. Out of the entire sample of 32 subjects, six patients (19%) had significant post-operative pyrexia of whom four were in the group with post-hysterectomy vaginal vault collection and two had no collection on their early post-operative scans. All collections detected on the early scans had resolved or were smaller on follow-up scan but two asymptomatic patients who had no collection on the early scan had developed vaginal vault fluid collections on the late follow-up scan. No statistically significant association was demonstrated between the presence of a collection and post-operative pyrexia, surgical approach or operative blood loss The results of this study indicate that the demonstration of vaginal vault collection following hysterectomy is a frequent finding in both febrile and afebrile subjects and does not indicate the need for drainage.

Sonographic assessment of the vaginal vault following hysterectomy

OBJECTIVE

A prospective study to determine the sonographic appearance of the vaginal vault following hysterectomy.

METHODS

A transvaginal sonographic examination of the vaginal vault on the third postoperative day. Follow-up to determine the incidence of postoperative morbidity.

RESULTS

An accurate sonographic examination of the vaginal vault was possible in 66/71 cases (92.9%). Fluid collections were visible in 28/66 cases (42.4%), and measured up to 41.1 cm2 in the transverse plane and 30.2 cm2 in the sagittal plane. There was no correlation between the presence of a collection and indices of postoperative morbidity.

CONCLUSION

Collections of fluid at the vaginal vault are common after hysterectomy, but do not usually contribute to postoperative morbidity.

Seromas in residual fibrous capsules after explantation: mammographic and sonographic appearances

PURPOSE

To evaluate the mammographic and sonographic findings associated with seromas that develop in residual fibrous capsules after explantation of breast prostheses.

MATERIALS AND METHODS

Preoperative and postoperative mammograms were reviewed in 86 patients (mean age, 51 years; age range, 24-71 years) who had undergone surgical explantation of breast prostheses. Six seromas were found in four patients 46-68 years of age. Imaging findings were correlated with surgical and laboratory results for three seromas. A presumptive diagnosis was made of the other three lesions.

RESULTS

Mammograms demonstrated all seromas as large, elliptic, water-opacity masses, some with well-circumscribed and some with irregular borders. Sonograms showed thin, compressible masses, two of which were flat and anechoic and one of which was hypoechoic. Three patients' images were initially misinterpreted, leading to excision of two seromas and aspiration of one. Seromas were not identified in patients whose implants were removed by means of complete capsulectomy.

CONCLUSION

Radiologists must be aware of the imaging findings associated with seromas and of a patient's surgical history to avoid biopsy of benign lesions.

Technical note: identifying and aspirating hip effusions

Ultrasound has become a routine investigation in the investigation of the painful hip in children. It has been recommended that all effusions demonstrated by sonography be drained. Based on the experience of 800 hip aspirations, the authors describe an approach to the demonstration and aspiration of hip effusions with some of the pitfalls that result in false positive and false negative diagnoses.

A novel ultrasonic technique for differentiating cysts from solid lesions: preliminary results in the breast

The feasibility of a new ultrasonic technique to distinguish cysts from solid lesions is explored. High intensity pulses are used to induce acoustic streaming in cyst fluid, and this motion is detected using Doppler techniques. Acoustic streaming cannot be generated in solid lesions, therefore, its detection would indicate a cyst. In six of seven breast cysts motion was clearly generated and detected in vivo. Ultrasonic pulses with intensities up to 4.4 W cm-2 (I(spta) in water) were focused on the cysts for 10 s. Lesion diameters ranged from 0.6 to 2.5 cm; induced flow velocities were less than 4.0 cm s-1.

Sonographic detection of hematomas and fluid after imaging guided core breast biopsy

We investigated sonographic changes to the breast after imaging guided core breast biopsy. We studied 31 breast lesions in 29 patients before, immediately after, and 2 to 9 days after core biopsy looking for hematomas. We found sonographic changes to the breast consistent with fluid collections after core biopsy in seven of 31 breast lesions (23%). Of the biopsy sites with sonographic changes, evidence suggested that six of 31 (19%) likely had hematomas. Sonographic changes after core breast biopsy are common and the formation rate of suspected hematomas is greater than previously believed although generally not clinically significant.

Knee effusions, radiology and acute knee trauma

Sixty patients with acute knee trauma were examined radiographically at presentation and subsequently examined under anaesthetic, when arthroscopy was performed. The aim was to assess whether a normal radiograph at presentation excluded significant knee pathology. Nine patients with significant pathology (25%) had normal radiographs at presentation.

[The early recognition of infected fluid collections in acute pancreatitis in computed tomography]

Infected accumulations of abdominal fluid are a severe complication and the major cause of death (mortality rate between 20 and 60%) in patients suffering from acute pancreatitis. In 93 patients with confirmed acute pancreatitis including 28 with surgically confirmed pancreatic abscess CT findings (volume of pancreatic and extrapancreatic necrosis, capsular enhancement, gas bubble formation and contact between fluid collection and intestinum) were retrospectively correlated with clinical and operative data to assess abscess formation. This revealed a sensitivity of 0.57 in respect of pancreatic necrosis; for extrapancreatic necrosis the sensitivity was 0.39, for capsular enhancement 0.5, for gas bubble formation 0.46 and for intestinal contact 0.93. The specificity was high for gas bubbles (1.0) and intestinal contact (0.91) and low for the other criteria.

IN CONCLUSION

There is a strong relationship between fluid accumulations in direct contact with intestinal structures and the occurrence of abscess. This parameter enhances the reliability of CT in the early detection of extrapancreatic infection.

Gallbladder injury secondary to blunt trauma: CT findings

OBJECTIVE

Our objective was to determine CT findings of gallbladder injury secondary to blunt trauma.

MATERIALS AND METHODS

Computed tomography scans and medical records of seven patients diagnosed with gallbladder injury secondary to blunt trauma, including six surgically confirmed cases and one presumptive diagnosis based on CT findings, were reviewed retrospectively to delineate CT findings associated with gallbladder injury. Evaluation of CT scans included assessment of gallbladder distention, wall thickness and contour, intraluminal contents, presence of pericholecystic fluid, and associated injuries. Data obtained included age, gender, mechanism of injury, surgical and pathologic findings when available, treatment, morbidity, and mortality.

RESULTS

Four patients had gallbladder contusions and three had either gallbladder laceration, partial avulsion, or intraluminal hemorrhage. The spectrum of CT findings included pericholecystic fluid (seven), ill defined contour of the gallbladder wall (four), high density intraluminal hemorrhage (four), mass effect on the duodenum (three), and gallbladder collapse (one). No combination of findings was specific for the type of injury. The most common associated injuries were pericholecystic liver lacerations and duodenal hematoma or perforation.

CONCLUSION

The CT finding of an ill defined contour of the gallbladder wall, a collapsed lumen, or high density intraluminal hemorrhage, especially in the presence of pericholecystic fluid, strongly suggests primary gallbladder injury.

Pleural exudates and transudates: diagnosis with contrast-enhanced CT

PURPOSE

To determine the accuracy of computed tomography (CT) in enabling differentiation of pleural exudates from transudates.

MATERIALS AND METHODS

Eighty consecutive patients (86 effusions) underwent contrast-enhanced CT. Thoracentesis was performed to measure pleural and serum total protein and lactate dehydrogenase (LDH) values. Effusions were classified as exudates with accepted criteria. CT scans were evaluated for the presence and appearance of parietal pleural and extrapleural fat thickening.

RESULTS

Fifty-nine effusions were exudates and 27 were transudates. Thirty-six of the 59 exudates (61%) were associated with parietal pleural thickening. All cases of empyema and 56% of the parapneumonic exudative effusions had pleural thickening. The specificity of this finding in diagnosing the presence of an exudate is 96%.

CONCLUSION

Parietal pleural thickening at contrast-enhanced CT almost always indicates the presence of a pleural exudate. A pleural exudate in the absence of pleural thickening occurs most frequently in patients with malignancy or uncomplicated parapneumonic effusion.

Effect of exercise on 99mTc-DTPA clearance from knees with effusions

OBJECTIVE

To devise and use a method for assessing the effect of dynamic exercise on synovial blood flow in knees with effusions.

METHODS

The clearance rate of intraarticular 99mTc-DTPA (diethylene triamine pentaacetic acid) was continuously monitored by a gamma camera during periods of rest or flexion. The rate of 99mTc-DTPA disappearance during a fixed period of exercise which was interposed between 2 rest periods was estimated by extrapolation between the clearance curves for the 2 rest periods.

RESULTS

Cycling and walking increased the clearance rate, straight leg raising had no effect, and flexion decreased the clearance rate.

CONCLUSION

Our results suggest that some dynamic exercises can increase the rate of synovial blood flow in joints with effusions. This outcome may be beneficial in inflamed joints which are chronically hypoxic due to elevated intraarticular pressure and consequent chronic synovial ischemia.

Allergen-induced biphasic plasma exudation responses in guinea pig large airways

In this study involving sensitized guinea pigs (anesthetized intramuscularly with a 3:2 mixture of ketamine+xylazine, 1 ml/kg), we applied allergen (ovalbumin) selectively to the tracheobronchial mucosa (sparing the nasal passages and the terminal airways) and examined the occurrence of immediate and late-phase inflammatory exudation of plasma and plasma-derived mediators (bradykinins) into the airway lumen. The experiments were terminated 10 to 480 min after challenge. A selective lavage that sampled the surface liquids of the extrapulmonary bronchi and the lower trachea was performed. The amount of plasma (microliter) was determined by analysis of a plasma tracer, [125I]albumin, in lavage fluid and blood (plasma) samples. Ovalbumin, 3 to 12 pmol, and histamine, 5 and 10 nmol, produced a dose-dependent immediate exudation response (p < 0.001). The effects were nonneurogenic because they were not affected by topical lidocaine given in a dose (3 nmol) that prevented the exudative effect of capsaicin. The 6- and 12-pmol doses of ovalbumin (but not 3 pmol) produced a significant late-phase exudative response at 5 h (p < 0.001), and both the immediate and late phases were associated with increased (p < 0.01 to p < 0.001) levels of bradykinin in the lavage fluids. Histamine, even in doses that produced a greater early response than the allergen, did not produce a late-phase response. A single topical dose of an antiasthma steroid (budesonide, 12 mumol/kg) administered just before ovalbumin (6 pmol) had little effect on the immediate response but inhibited the late-phase response (p < 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

[Radiodiagnosis of postnecrotic complications of caudal pancreatitis]

The left kidney and pararenal connective tissue were involved in the process in 3 cases of 5 with caudal pancreatitis complications. A complex of radiodiagnostic methods including, besides x-ray examinations, ultrasonic method and computer-aided tomography, was used to detect the routes of exudate dissemination from the caudal portion of the pancreas into cellular spaces. If a destructive or interstitial form of chronic pancreatitis is detected, radiation screening of all the possible routes of the exudate dissemination (omental sac, left subdiaphragmatic space, left pararenal area, and the lateral canal) is recommended. Detection of pathologic formation in these areas implies thorough examinations of the pancreas making use of x-ray, ultrasonic, and endoscopic methods to rule out or confirm pancreatitis.

[The percutaneous aspiration and drainage of infected fluid retention after organ transplantation]

Local postoperative infections in immunosuppressed patients carry a high mortality rate. In this group of patients interventional radiological procedures are particularly valuable in diagnosis and treatment. We report on the results of radiologically controlled aspirations (11 cases) and drainage (37 cases) of infected fluid collections in 47 patients following transplantation of various organs. By percutaneous aspiration or drainage, 91.7% of infected fluid collections were successfully treated or the clinical condition of the patient improved so that surgical intervention could be avoided. The causative organism was identified and antibiotic treatment carried out in 72.9% (35 cases). Surgical intervention was necessary in only 4.3% (2/48). Needle aspiration or drainage of percutaneously accessible fluid collections thought to be infected appears to be particularly useful for transplant patients at increased risk and is a good alternative to surgical treatment.

Bilateral perinephric fluid accumulation: an unusual manifestation of pulmonary hypertension--a case report

This is the case report of a forty-seven-year-old man with an ostium secundum atrial septal defect and a very high grade of pulmonary hypertension, associated with a large bilateral perinephric fluid accumulation. The fluid accumulation was remarkably reduced after eleven phlebotomies over a twelve-month period. A pathogenetic relation with the Eisenmenger's syndrome is discussed. No previous report of this association has been found in a survey of the literature.

[Measurement of the subretinal fluid volume using B-scan ultrasonography. Report 2. Measurement of the decrease rate of subretinal fluid in patients with rhegmatogenous retinal detachment]

I have previously reported the use of video-ultrasonography and an image computerized system to measure the volume of subretinal fluid (SRF). This measurement system was now used for 19 eyes with rhegmatogenous retinal detachment during absolute rest in bed for 24 hours and double patching. The mean age was 55 years (range, 18-69 years). The retinal detachment involved two quadrants or less of the retina in all eyes. The decrease rate of SRF was 0.051 +/- 0.033 microliter/mm2/hour (mean +/- standard deviation); 0.074 +/- 0.033 microliter/mm2/hour in 9 eyes in which the duration of retinal detachment was 14 days or less and 0.030 +/- 0.009 microliter/mm2/hour in 4 eyes in which the duration was 15 days or more. The rate was 0.032 +/- 0.009 microliter/mm2/hour in 3 eyes with atrophic holes. Three eyes with macular holes, which had retinal detachment underlying extensive staphyloma showed a rate of 0.028 +/- 0.022 microliter/mm2/hour. Though absolute rest in bed and double patching cannot completely block a transfer of fluid from vitreous to subretinal space via retinal break, the decrease rate of SRF appears to reflect the absorption of SRF across the retinal pigment epithelium.

Ultrasonography in detection of effusion in the radiocarpal and midcarpal joints

Sixty radiocarpal and midcarpal joints in 30 healthy adults and 20 swollen wrists in 20 patients with chronic arthritis were examined by dorsal longitudinal ultrasonography (US). In five other patients intraarticular application of fluid into the radiocarpal joint could be seen as a change in the US scan. In 49 out of the 60 healthy wrists the unechogenic zone dorsally above the scaphoid bone was less than two millimetres, and the measurement did not change in dorsal or volar flexion. The side difference was less than one millimetre. In the healthy wrists the midcarpal area above bones was echogenic in US. In 15 radiocarpal and in 10 midcarpal joints out of the 20 swollen wrists, effusion could be depicted with US as an unechogenic zone. It was two millimetres or more in radiocarpal joint and it got bigger in dorsal and smaller in volar flexion.

Ultrasonography in slipped capital femoral epiphysis. Diagnosis and assessment of severity

We used ultrasonography to study 26 hips with slipped capital femoral epiphyses. In recently slipped epiphyses the ultrasound image revealed a step at the anterior physeal outline (mean 6.4 mm), diminished distance between the anterior acetabular rim and the femoral metaphysis (mean 4.3 mm) and an effusion. As metaphyseal remodelling progressed the physeal step decreased. The femoral neck appeared straighter in hips which had been symptomatic for longer than three weeks. It was possible to measure posterior epiphyseal displacement without projectional errors and the method was accurate in diagnosing minimal slip and in staging displacement. The suggested criteria are, less than 7 mm for a mild slip, 7 to 11 mm for a moderate slip and more than 11 mm for a severe slip. We recommend ultrasonography for the diagnosis, staging and follow-up management of slipped upper femoral epiphysis.

Real-time digital contrast enhancement and magnification in the assessment of acute elbow injuries

The elbow is a common site of injury and missed fractures may lead to disability and litigation. An assessment was made of a commercially available desk-top digital contrast enhancement and magnification unit (DETECT system) in a series of 320 patients with an acute elbow injury. Five radiologists of varying experience independently viewed elbow radiographs on a conventional light-box, and subsequently using the digitizer, indicating the presence or absence of a fracture. The overall results demonstrated no difference in performance when using the unit, though small improvements in the confidence with which a definite diagnosis was made were observed. Assessment of soft tissues with the digitizer was less reliable.