Postsurgical biliary tract complications

Cholecystectomy and other biliary tract operations are being performed with an increasing frequency due to the prevalence of gallstones and pancreaticobiliary disorders among the aging population of the United States. Even in the current era of modern medicine, however, a wide spectrum of postsurgical biliary complications are encountered. Most are the result of preventable iatrogenic trauma or technical mishaps that occur with a much higher incidence during laparoscopic cholecystectomy than the conventional open procedure. These include bile leakage from an overlooked transection of normal or aberrant bile ducts, obstructive jaundice due to inadvertent ligation of the common duct or its postsurgical stricture, instrumentation injuries induced during biliary tract exploration, and the various types of biliary fistulas. These lesions are detectable by intraoperative or T-tube cholangiography, if the examination is performed and interpreted correctly. In most instances, however, the postoperative evaluation of the abdomen by computed tomography or ultrasonography will provide the initial clues to an otherwise unsuspected lesion. Radiologic imaging and interventional techniques play a crucial role in the diagnosis and management of postsurgical biliary tract complications, as illustrated in this review article.

Gastric cancer. Radiologic diagnosis

The development and refinement of double-contrast barium techniques over the past two decades have dramatically improved the radiologist's ability to detect gastric cancer and characterize gastric ulcers. This article presents the radiologic findings of both early and advanced gastric cancer and offers guidelines for differentiating benign versus malignant gastric ulcers.

Gastric cancer. Radiologic staging

CT scan and EUS play complementary roles in staging gastric cancer. CT scan is initially performed to detect local and distant metastases. Depending on institutional expertise, EUS may be considered for local staging. Laparoscopic staging may also be helpful in select patients. It is hoped that further improvements in these techniques will improve the ability to stage gastric cancer and thereby optimize patient treatment and outcome.

Detection of occult esophageal narrowing with a barium tablet during chest radiography

Dysphagia is a delayed symptom of esophageal constriction and often appears after the luminal diameter is reduced to less than 10 mm. Earlier diagnosis of benign or malignant strictures while clinically silent would be desirable; hence we investigated the detectability of occult esophageal lesions with the aid of an ingested barium tablet during routine chest radiography. We prospectively examined 300 patients older than 40 years, who were referred for chest films because of indications unrelated to the upper gastrointestinal tract. Each patient was instructed to swallow a 12.5-mm barium tablet with 100 mL of water immediately prior to the exposure of posteroanterior and lateral chest films. Radiographs of 17 patients (5.6%) revealed intraesophageal retention of the tablet, and their prompt evaluation with double-contrast esophagrams confirmed various structural or functional abnormalities in 15 patients. Therefore, the oral administration of a barium tablet during routine chest radiography is a simple efficacious method to assess esophageal patency and detect occult narrowings from structural or functional causes.

Radiologic features of carcinomas arising in hiatal hernias

OBJECTIVE

The aim of this study was to present the spectrum of clinical and radiologic manifestations of carcinomas that originate within hiatal hernias, to emphasize their increasing prevalence among the elderly patient population, and to assess the reasons for radiologic misdiagnosis.

MATERIALS AND METHODS

Medical records and radiologic studies of 27 adult patients (15 men and 12 women; 54-83 years old [mean, 71 years old]) with surgically proven adenocarcinomas in the herniated proximal part of the stomach were reviewed.

RESULTS

A hiatal hernia with intrinsic abnormalities suggestive of carcinoma was shown by upper gastrointestinal tract examination obtained before surgery in all 27 patients. A diagnosis of malignancy was reported at the time of examination for 24 patients (89%); for the remaining three patients, diagnosis was made by endoscopy. The predominant feature, seen in 15 patients (56%), was an infiltrative process that caused deformity and rigidity of the hiatal hernia in conjunction with thickened, nodular mucosa. The intrahernial tumor appeared as a well-demarcated sessile polyp or lobulated mass in nine patients (33%) and as ulcerations and eccentric wall thickening in three patients (11%). All errors were perceptive in nature. On review, we saw minimal evidence of infiltration or small polypoid masses.

CONCLUSION

Although some of the radiologic abnormalities were minimal, our review of 27 cases in a biphasic upper gastrointestinal tract series resulted in detectable radiographic findings of carcinomas associated with hiatal hernias for all cases. Meticulous assessment of the herniated fundus and gastroesophageal regions is crucial for the detection of such tumors.

Radiologic investigation of acute inflammatory and infectious bowel disease

Definitive diagnosis of infectious or idiopathic inflammatory bowel disease ultimately rests on histologic and bacteriologic documentation. Nevertheless, radiologic studies play an important role in the evaluation and management of patients with acute enterocolitis. Plain abdominal films can give a gross estimate of disease extent in the colon and detect complications, such as perforation or toxic megacolon. Double-contrast barium enema allows visualization of the mucosal pattern and the overall configuration of the bowel, which are important for determining the extent and severity of disease and its most likely cause. Cross-sectional imaging depicts the mural and mesenteric involvement as well as intraperitoneal complications of inflammatory bowel disease, thus providing a critically important perspective that complements the information afforded by endoscopic and conventional radiographic techniques.

Idiopathic localized dilatation of the ileum in adults: findings on barium studies

OBJECTIVE

Idiopathic localized dilatation of the ileum is a rare entity characterized by a sharply demarcated segmental dilatation of the small bowel that is in line with the lumen. It is probably congenital in origin. Although more commonly diagnosed in children, it presents in adults as occult gastrointestinal (GI) bleeding or less often with abdominal pain. On pathologic examination, the mucosa may be ulcerated, but otherwise the wall is relatively normal. We analyzed the radiographic findings in nine previously unreported cases of this condition in adults.

MATERIALS AND METHODS

Collaborative efforts resulted in the collection of nine cases from multiple institutions. In five cases, an enteroclysis had been performed; in three, a conventional small bowel series had been performed; and in one, the lesion was seen on a barium enema with reflux into the ileum. The mean age of patients was 52 years. In seven cases, pathologic correlation was available. In the other two patients, long-term clinical follow-up and repeat studies confirmed the diagnosis. Resected specimens showed a thin but otherwise normal wall with normal ganglion cells and nerve plexuses. Ulceration was noted in six of the seven resected cases. Two cases contained heterotopic gastric mucosa. GI bleeding and/or anemia was the most common (77%) presenting symptom. Abdominal pain and/or obstruction was present in slightly less than half the patients (44%).

RESULTS

Lesions were 6-21 cm long and 4-13 cm wide, and all were located in the ileum. The dilated segments were bilobate in three cases, multilobate in three, spherical in two, and tubular in the other. The dilated area was always in line with the long axis of the bowel, not projecting to the side. No surrounding masses were seen. Except in three patients in whom ulcers were noted, the mucosa was normal.

CONCLUSION

Idiopathic localized dilatation of the ileum should be suspected whenever a sharply demarcated area of lobulated small bowel dilatation is seen in a middle-aged patient with occult GI bleeding. The axial orientation distinguishes this condition from small bowel diverticula (including Meckel's). The lack of surrounding mass, mucosal irregularity, hypermotility, or fistulae help differentiate it from other causes of small bowel dilatation.

Passive hepatic congestion: cross-sectional imaging features

Passive hepatic congestion is caused by stasis of blood within the liver parenchyma due to compromise of hepatic venous drainage. It is a common complication of congestive heart failure and constrictive pericarditis, wherein elevated central venous pressure is directly transmitted from the right atrium to the hepatic veins because of their close anatomic relationship (Fig. 1). The liver becomes tensely swollen as the hepatic sinusoids dilate and engorge to accommodate the backflow of blood. A variety of structural and functional hepatic derangements develop that have distinctive appearances on sonograms, CT scans, and MR images.

Radiologic evaluation of suspected gastrointestinal perforations

Perforation of the alimentary tract may occur spontaneously in various gastrointestinal diseases or develop due to an ingested foreign body, iatrogenic complication, and blunt or penetrating injuries. The detection of extraluminal air on radiographs of the chest or abdomen is often the initial clue to the diagnosis. It may not, however, be visible when the perforation is small, rapidly sealed, or well contained. Further evaluation by special radiographic techniques, gastrointestinal studies using contrast media, or CT examination can demonstrate the site and nature of the perforation. This article reviews the clinical features and methods for radiologic assessment of suspected perforations involving the upper gastrointestinal tract, small bowel, or colon and rectum.

Carcinoma arising in urinary bladder diverticula: imaging findings in six patients

OBJECTIVE

Carcinoma arising within urinary bladder diverticula has a poorer prognosis than do neoplasms that originate within the main bladder lumen as a result of early transmural tumor infiltration. Imaging plays an important role in diagnosing and staging the disease. We describe the radiologic findings in six patients with pathologically proved diverticular carcinomas.

MATERIALS AND METHODS

We reviewed the records of six patients who had radiologic examinations and surgically confirmed vesical diverticular carcinomas. The examinations included excretory urography in three patients, cystography in three patients, CT in five patients, and MR imaging in one patient. All patients had hematuria. Five patients had transitional cell carcinoma, and one patient had squamous cell carcinoma.

RESULTS

Three of the tumors manifested as an intraluminal filling defect within a bladder diverticulum on excretory urograms or cystograms. In one patient, CT scans showed a concentric soft-tissue tumor in a diverticular neck. Correlative cystograms showed only smooth narrowing in this area. CT and MR imaging showed a tumor within a large diverticulum, which was not visualized on cystograms because of obstruction at the diverticular orifice.

CONCLUSION

Imaging plays an important role in identifying bladder diverticula as a potential site of occult neoplasm.

Imaging manifestations of pleural tumors

Although radiologic assessment of pleural tumors may be accomplished with several imaging modalities, the standard noninvasive techniques include chest radiography and computed tomography (CT). These examinations may be supplemented with magnetic resonance imaging and occasionally with ultrasound. Depending on the location, size, and underlying histologic features, pleural tumors may produce a spectrum of findings. CT is particularly useful in defining the location and extent of these masses. The authors present a review of basic pleural anatomy and imaging features of both benign and malignant pleural neoplasms. The pleural may be involved by one of several primary or metastatic tumors. Specific cell types are diffuse malignant mesothelioma (the most common plain radiographic findings are unilateral pleural effusion and pleural thickening), localized fibrous tumor (circumscribed, spherical or ovoid, noncalcified lesions arising in the pleural surface), metastatic disease (radiographic findings may mimic those of malignant mesothelioma), and uncommon neoplasms including thymoma and lymphoma. Among these various pleural tumors, metastatic disease represents the most common neoplasm.

Appendices epiploicae of the colon: radiologic and pathologic features

Appendices epiploicae are adipose structures protruding from the serosal surface of the colon. They can be seen with abdominal radiography and cross-sectional imaging if the colonic wall is surrounded by intraperitoneal contrast material, ascites, or blood. Normal appendices epiploicae appear as lobulated masses of pericolic fat, usually 2-5 cm long and 1-2 cm thick. Their enlargement, deformity, or altered radiopacity may result from various pathologic processes that can originate locally or extend from adjacent viscera. In a series of 22 cases, appendices epiploicae were affected by spontaneous torsion and hemorrhagic infarct, calcification due to aseptic fat necrosis, primary or secondary inflammation, enlargement by lipomas or metastases, and incarceration in hernias. Disorders of appendices epiploicae are often manifested by nonspecific clinical signs and symptoms (eg, torsion is often mistaken for appendicitis or diverticulitis). These entities should be included in the differential diagnosis of any unexplained abdominal pain or pericolic lesions in adults.

Hyperplasia of Brunner glands: the spectrum of its radiographic manifestations

Radiographic features of the duodenal mucosa were analyzed in a series of 26 patients in whom the diagnosis of Brunner gland hyperplasis (BGH) had been established by endoscopic biopsies. The observed mucosal patterns could be classified into five categories: (1) focal BGH causing a solitary submucosal adenoma or a cluster of sessile polyps in the otherwise smooth duodenal bulb surface (five cases); (2) diffuse BGH manifested by a myriad of small and uniform mucosal elevations (six cases); (3) multifocal BGH producing large and well-demarcated polygonal masses (six cases); (4) BGH with concomitant acute and/or chronic duodenitis showing marked thickening and nodularity of duodenal folds (four cases); or (5) BGH with predominant erosive duodenitis, leading to ulcerations (five cases). These radiographic findings showed a good correlation with the endoscopic and histopathologic manifestations of BGH and the frequently coexistent duodenitis.

Sciatic hernia with incarcerated ileum: CT and radiographic diagnosis

An elderly woman presented with postprandial cramps in the right lower abdomen and recurrent episodes of low back pain radiating down to the dorsal aspect of her right thigh. Computed tomography (CT) of the pelvis and barium enema with small bowel reflux demonstrated the herniation of an ileal loop through the greater sciatic foramen on the right side. The diagnosis and management of this case are herein described and previous publications on sciatic hernias are reviewed.

Evolution of pulmonary pseudolymphomas: clinical and radiologic manifestations

Solitary or multifocal pulmonary pseudolymphoma developed in two men and two women between 59 and 76 years of age. The lesions were detected incidentally in three patients and following a respiratory infection in the fourth. Follow-up radiographs and chest CT revealed gradual expansion of the opacities without cavitation, calcification, or pleural involvement. Histopathologic sections from open lung biopsies or resected segments showed dense alveolar and peribronchial infiltration by numerous mature lymphocytes and plasma cells surrounding reactive lymphoid follicles with true germinal centers. Their benign nature was confirmed by immunofluorescent studies showing polyclonal cell populations. No recurrence or malignant change occurred during 4- to 9-year periods of observation. The clinical and radiologic features of pulmonary pseudolymphoma are presented with a brief review of 54 previously reported cases.

Diverticulitis of the duodenum: clinical and radiological manifestations of seven cases

Seven patients with duodenal diverticulitis were evaluated by computed tomography (CT) and various other abdominal imaging techniques. The series included four men and three women who ranged in age from 47 to 84 yr (mean: 65 yr). They had presented with epigastric or periumbilical pain, low-grade fever, leukocytosis, and loss of appetite and weight due to postprandial cramps or vomiting. In each instance, the abdominal CT examination proved crucial in the diagnosis of duodenal diverticulitis, with contained perforation or inflammatory changes involving the adjacent structures. Five patients underwent laparotomy while two others were treated conservatively with antibiotics and/or percutaneous drainage of peridiverticular abscess. The clinical and radiological features of this uncommon entity are herein described, along with a brief review of the medical literature regarding the current approach to its diagnosis and management.

Iatrogenic biliary tract complications: radiologic features and clinical significance

Thirteen intrahepatic and 22 extrahepatic biliary tract complications were detected radiologically in 35 adult patients who had undergone cholecystectomy and bile duct exploration. Intraoperative usage of Fogarty balloon catheters to extract biliary calculi without fluoroscopic guidance resulted in focal ectasia or rupture of intrahepatic radicles in two and seven cases, respectively. Metallic surgical instruments such as Bakes dilators and biliary forceps or clamps accounted for most of the common duct injuries; these were manifested as submucosal dissection (two cases), transmural laceration (four cases), or localized trauma with subsequent stricture (three cases). Technical mishaps during T-tube placement led to common duct perforation (four cases) and extraluminal malposition of T tubes (three cases). The remaining complications included choledochoduodenal fistula (three cases), biliovenous fistula (two cases), biloma (three cases), and retained intraductal fragments of biliary drainage catheters (two cases). Knowledge about radiologic features and causal factors of such iatrogenic processes can play a crucial role in their prevention, correct diagnosis, and management.

CT diagnosis of postoperative abdominal complications

Over 3 million abdominal operations are performed in the United States each year, and a significant number of these patients subsequently undergo computed tomography (CT) either for follow-up of resected lesions or evaluation of possible postoperative complications. This article describes the clinical presentations and CT features of commonly encountered postsurgical complications. A wide spectrum of lesions involving the abdominal wall as well as intraperitoneal structures is herein illustrated to emphasize the role of CT in their diagnosis and management.

Acquired malposition of the colon and gallbladder in patients with cirrhosis: CT findings and clinical implications

Topographic relationships among the gallbladder, liver, hepatic flexure of the colon, right hemidiaphragm, and anterolateral peritoneal reflection were evaluated with computed tomography in 75 patients with biopsy-proved cirrhosis and in 200 control subjects to determine the effect of cirrhotic liver morphology on the anatomy of the right upper quadrant of the abdomen. Interposition of the colon between the liver and anterolateral abdominal wall and/or diaphragm was seen in 18 of the 75 (24%) cirrhotic patients and in six of the 200 (3%) control subjects. There was a strong correlation among gallbladder malposition, colonic interposition, and a ratio of transverse caudate lobe width to right lobe width (C/RL) exceeding 0.60. Patients with cirrhosis, colonic interposition, and gallbladder malposition had a mean C/RL of 0.62, compared with a mean of 0.50 for cirrhotic patients without interposition (P less than .0001). The mean C/RL for control subjects without interposition was 0.43, as compared with 0.69 for control subjects with interposition (P less than .01). These acquired malpositions of the colon and gallbladder may pose a diagnostic dilemma and increase the risk of inadvertent injury during percutaneous liver biopsy, interventional biliary tract procedures, and laparotomy.

Colorectal carcinomas: diagnostic implications of their changing frequency and anatomic distribution

This retrospective review included 1,694 consecutive cases of colorectal carcinoma diagnosed at the University of Chicago Medical Center during a 25-year period (1960 through 1984). The number and percentage of tumors occurring within 7 anatomic segments of the large bowel were determined. The statistical data for a recent 5-year interval were then compared with those of the 2 preceding decades. There was a 10.2% increase in the frequency of cancers originating in the cecum or ascending colon, while rectal and rectosigmoid carcinomas declined by 15.8% during the same study period. These data provide further evidence for a progressive left-to-right shift in cancer distribution within the colon during the past quarter century. Currently, the most proximal and distal 20-25 cm segments of the large bowel (cecum or ascending colon versus rectum and rectosigmoid) each harbor approximately 25% of the tumors. Therefore, the classic medical teaching that over 50% of colorectal cancers would be detectable by digital examination and/or proctosigmoidoscopy is no longer accurate. This documented increase in proximal colon cancers and redistribution of lesions within various large bowel segments indicate the growing importance of barium enema and colonoscopy as the optimal techniques for detection of colorectal neoplasms.

Heterotopic gastric mucosa in the duodenum: radiographic findings

Heterotopic gastric mucosa in the duodenal bulb was detected by endoscopic examination in 25 adult patients and was confirmed by biopsy in 17 of these patients. The endoscopic findings were correlated with the radiographic features of the lesion on upper gastrointestinal barium studies. On radiographs, this entity usually presented as clusters of 1- to 3-mm plaques raised above the smooth and featureless duodenal mucosa; this was seen in 17 (68%) of 25 patients. A less frequent finding was patches of coarse nodular mucosa with superficial erosions or an ulcer crater (five cases [20%]). The heterotopic gastric mucosa was visible as polypoid masses in two patients and as prominent areae gastricae covering the base of duodenal bulb in another.

Complications of endoscopic gastrostomy: pneumoperitoneum and volvulus of the colon

Pneumoperitoneum caused by percutaneous gastrostomy usually follows a benign clinical course, but led to progressive volvulus of the ileocolic segment in the patient described here. This article explains relationships between pneumoperitoneum after surgical or endoscopic procedures and volvulus involving the intraperitoneally mobile intestinal loops.

Crohn's disease of the duodenum complicated by adenocarcinoma

Patients with Crohn's disease of the small bowel or the colon are at risk for development of cancer within their chronically inflamed intestinal loops. We present here the first reported case of malignant degeneration of duodenal mucosa involved by Crohn's disease. The clinical observations as well as radiographic and endoscopic features of this unusual complication are described.

Appendicitis as the initial manifestation of Crohn's disease: radiologic features and prognosis

Twenty-five patients 15-47 years old presented with appendicitis as the initial manifestation of Crohn's disease. This entity accounted for 1.8% of all appendicitis patients undergoing surgery at our institution during a recent 9-year period. Preoperative radiologic studies in 18 (72%) of 25 cases showed abnormalities indicating the presence of appendicitis or periappendiceal abscess, but not the specific diagnosis of Crohn's disease as the underlying cause. Histopathologic evidence for an isolated, transmural, or granulomatous appendicitis was found in 20 patients; in two of these there was a local recurrence within 3 years after surgery, while 18 others have remained asymptomatic during follow-ups of up to 8 years. In the other five patients Crohn's disease caused appendicitis with concurrent inflammation of the cecum or terminal ileum; three of these cases were complicated by progressive granulomatous ileocolitis within 2 years. The data presented herein indicate that Crohn's disease can originate in and be confined to the appendix, yet manifest clinical symptoms leading to emergency laparotomy; preoperative radiologic findings are similar to those of suppurative appendicitis, but visualization of a markedly thickened appendiceal wall with patent or irregularly narrowed lumen supports the diagnosis of Crohn's appendicitis; and primary Crohn's disease of the appendix has a favorable long-term prognosis after simple appendectomy, despite a 10% incidence of recurrence as granulomatous ileocolitis.

Laminated radiopaque enteroliths: diagnostic clues to intestinal pathology

Laminated intestinal calculi were detected during radiographic evaluation of the abdomen in 14 adult patients. These enteroliths had developed in the distal ileum of 12 patients who had either a Meckel's diverticulum (four cases) or a variety of other lesions causing local stasis, including strictures due to Crohn's ileitis, ileocecal tuberculosis, radiation enteritis, and peritoneal adhesions. Only two patients had enteroliths in the colon proximal to strictures complicating ulcerative colitis. The clinical and radiological features of enterolithiasis as well as the mechanism of its formation are herein described.

CT diagnosis of occult incisional hernias

CT of the abdomen was performed on 14 adult patients 2-25 months after laparotomy in order to evaluate intraabdominal processes. Clinically unsuspected incisional hernias were detected in all cases. These herniations were not disclosed by previous physical examination because of the patients' obesity, abdominal pain, distension, or various other factors. However, CT scans showed the exact size, location, and content of each incisional hernia. The evaluation of postsurgical abdomen by CT should include a careful assessment of previous laparotomy sites in search of occult incisional hernias that may be the source of the patient's abdominal symptoms.

CT demonstration of fistula between esophageal carcinoma and spinal canal

A patient with recurrent carcinoma of the proximal esophagus after radiotherapy presented with bacterial meningitis. Esophagography and CT of the chest disclosed an esophagosubarachnoidal fistula extending between the ulcerated tumor, posterior mediastinum, and the thoracic spine.

Nasoenteric feeding tubes. Radiographic detection of complications

Recent technical refinement of feeding tubes and formula infusion pumps has led to widespread clinical use of long-term nasoenteric alimentation. We evaluated 340 hospitalized adults after placement of flexible, small-bore feeding tubes. These debilitated or critically ill patients were intubated transnasally at their bedside without fluoroscopic guidance, but portable radiographs of the chest and abdomen were obtained routinely for tube localization before administering liquid nutrients. Various complications were detected in 26 cases (7.6%). Tube malposition into the airways (seven patients) or within the pharynx and esophagus (eight patients) was the most common problem; it occurred in 4.4% of all cases. Radiographic findings in 11 other patients included tube-induced perforation of the lung (one case), massive aspiration (three), malfunction of knotted tubes (three), and rupture of their mercury capsule within the gastrointestinal tract (four). Our observations indicate a need for careful radiographic localization of the feeding tubes at the time of insertion and their periodic monitoring throughout the course of nasoenteric alimentation.

Duodenal manifestations of nontropical sprue

Barium studies of the upper gastrointestinal tract and small bowel were performed in 16 adult patients with biopsy-proven nontropical sprue. Commercially available contrast media containing micropulverized barium sulfate, suspending agents, and various other additives were used. Radiographs were analyzed for the incidence and pattern of duodenal vs. small-bowel changes associated with celiac disease. Thirteen of 16 patients (81%) demonstrated abnormalities of the duodenum which ranged from focal erosions to diffusely thickened and nodular folds. A nonspecific, mild dilatation pattern was present on the small-bowel series of 11 patients (69%). The classic radiographic signs of malabsorption, such as flocculation and segmentation, however, occurred in less than 20% of cases, apparently because of the stability of new barium suspensions. The pathogenesis of duodenal changes in sprue and its diagnostic implications are emphasized.

Arteriographic evaluation of postsurgical stomach

Visceral arteriography was performed in 35 adult patients who had undergone various types of gastric surgery. Nineteen of these patients had presented with gastrointestinal hemorrhage at different postoperative intervals (4 days-23 years). Arteriography showed the bleeding site in 14 (74%) and permitted its nonoperative control in 8 cases. Diffuse hemorrhage from the gastric pouch as well as localized bleeding from suture line, marginal or stress ulcers, and other sources were recognized. Arteriography was also crucial in the diagnosis of iatrogenic arteriovenous fistulas, telangiectasia in the anastomotic regions, inadvertently ligated arteries, and postoperative changes in the vascular architecture. Value and limitations of arteriography of the postsurgical stomach are presented together with a review of the pertinent literature.

Radiation-induced esophageal carcinoma

Radiation-induced carcinoma of the esophagus is rare and only 8 cases have been reported since 1957. This article presents 2 additional patients in whom esophageal carcinoma developed in segments previously exposed to large therapeutic doses of irradiation. The first patient had received 5,000 rads to her mediastinum and the second patient 3,200 rads to her neck region. The latent intervals were 11 years and 30 years, respectively.

Glycogenic acanthosis of the esophagus: radiographic and pathologic features

Diagnostic features of glycogenic acanthosis of the esophagus on air-contrast radiography, endoscopy, and histopathologic studies in 10 selected cases are presented. Glycogenic acanthosis of the esophagus is a common benign entity, characterized by multifocal plaques of hyperplastic squamous epithelium with abundant intracellular glycogen deposits. At esophagoscopy or on autopsy specimens these lesions appear as slightly raised grey-white plaques which are usually 2-10 mm in diameter and may be confluent. They cause a finely nodular or cobblestone mucosal pattern demonstrable on double-contrast views of the well-distended esophagus. The findings are not associated with mucosal ulcerations, luminal narrowing, or mobility disturbance, although some patients may have coexistent hiatal hernia and gastroesophageal reflux.

Burkitt's lymphoma of the stomach

An unusual case of American Burkitt's lymphoma originating in the stomach of an elderly man is presented. Computed tomography revealed diffuse infiltration of the gastric wall by a solid tumor measuring 2.5 to 5.5 cm in thickness. Despite such bulky tumor, however, distensibility of the stomach was preserved because Burkitt's lymphoma does not induce desmoplastic reaction and linitis plastica.

Internal abdominal hernias

Internal hernias are the underlying cause of acute or intermittent intestinal obstruction in approximately 4 per cent of cases. Their preoperative diagnosis depends on radiologic evaluation of the gastrointestinal tract with contrast material. This article presents the clinical and radiographic findings associated with various types of intra-abdominal herniations.

Prolapsing inflammatory pseudopolyp-fold complex of the oesophagogastric region

This article describes a series of 12 adult patients in whom a prominent and mobile polypoid fold of the oesophagogastric region was demonstrated radiologically. Subsequent endoscopic and histopathologic studies confirmed the presence of an inflammatory pseudopolyp at the squamocolumnar junction and contiguous with a thick gastric rugal fold. The clinical and radiographic features of this entity and the mechanisms of its formation are reviewed.

Lymphoma of the stomach following gastric surgery for benign peptic ulcers

Adenocarcinoma of the gastric stump is a well-known complication of gastroduodenal surgery for benign lesions. However, we report 2 unusual cases wherein malignant lymphoma originated in the postoperative stomach. The first patient had undergone partial gastrectomy and Billroth II procedure 20 years earlier. The gastric lymphoma of the second patient manifested 39 years after vagotomy and pyloroplasty. In both instances, the tumor caused marked thickening and nodularity of the rugal folds without affecting the distensibility of the previously operated stomach. Differential diagnostic features of the observed findings and the potential carcinogenic effects of gastroduodenal surgery are reviewed.

Diagnosis and management of intraluminal duodenal diverticulum

The descending part of duodenum is the principal site for an intraluminally projecting mucosal pouch or diverticulum, but this unusual lesion may also occur elsewhere in the upper gastrointestinal tract. We report three patients in whom a large intraluminal duodenal diverticulum (IDD) was diagnosed radiographically at the ages of 15, 27, and 68 years, respectively. Fiberoptic duodenoscopy was performed in the two symptomatic cases for the removal of impacted food from IDD or dilatation of its outflow aperture. Guidelines for the diagnosis and treatment of IDD are provided based on our experience and review of the pertinent literature.

Esophageal manifestations of Crohn's disease

Two patients with concurrent esophagitis and ileocolitis due to Crohn's disease are presented. The initial feature of esophageal involvement was dysphagia caused by severe inflammation of the distal esophagus with mucosal ulcerations and polypoid folds. Long-term observation of both cases revealed a gradually progressive course leading to development of rigid esophageal structure, intramural sinus tract, and esophagobronchial or esophagogastric fistulas. The clinical and radiographic manifestations of Crohn's esophagitis in these 2 patients and in 18 previously reported cases are reviewed.

Reappraisal of contrast media used to detect upper gastrointestinal perforations: comparison of ionic water-soluble media with barium sulfate

Iodinated water-soluble compounds have been widely recommended as the most suitable contrast media for diagnosis of gastrointestinal perforations. However, the authors present 6 cases in which mucosal tears and transmural perforations of the upper gastrointestinal tract were either unrecognizable or inadequately shown during initial evaluation with methylglucamine diatrizoate. Re-examination with barium sulfate demonstrated the precise location and extent of the perforations. Reasons for the higher diagnostic yield of barium studies are explained on the basis of experimental and clinical observations.

Idiopathic localized dilatation of the ileum in adults

The clinical and radiological features of idiopathic aneurysmal dilatation of the ileum in 3 adult patients are described. This uncommon lesion presents as an aperistaltic saccular segment in direct continuity with the normal ileal lumen. On barium examination of the small bowel, however, it may closely resemble and be mistaken for a Meckel's diverticulum. Previous reports about this entity manifesting in the pediatric age group are reviewed.

Calcified pseudocyst of the pancreas

Pancreatic pseudocysts are encapsulated collections of fluid which may complicate trauma or inflammation of the pancreas. The correct preoperative diagnosis of the pseudocyst can be established easily by the modern techniques of ultrasonography or computed tomography (1-3). However, recognition of the lesion on plain radiographs of the abdomen is rarely possible because the wall and content of pancreatic pseudocysts do not show a visually perceptible difference in density from the adjacent soft tissues (4). This report concerns an exceptional instance whereby a pancreatic pseudocyst was clearly demarcated by virtue of radiographically detectable calcium deposits in its wall.