Tracheotomy tube occlusion status and aspiration in early postsurgical head and neck cancer patients

The purpose of the present study was to investigate tracheotomy tube occlusion status and prevalence of aspiration utilizing videofluoroscopy. A prospective study was done of 16 consecutive, early, postsurgical head and neck cancer patients with tracheotomy. Selection criteria included the ability to tolerate tracheotomy tube occlusion prior to and during the modified barium swallow procedure, oral and/or pharyngeal surgical resection, no history of neurological disease or stroke, and medical clearance to begin oral feeding. There was 100% agreement among the independent reviewers on ratings of the presence or absence of aspiration. It was found that occlusion status of the tracheotomy tube did not influence the prevalence of aspiration in the immediate postoperative period. No trends were observed when comparing bolus consistency, type of tracheotomy tube, or presence/absence of a nasogastric tube and the ratings of aspiration.

Fiberoptic endoscopic evaluation of dysphagia to identify silent aspiration

The traditional bedside dysphagia evaluation has not been able to identify silent aspiration because the pharyngeal phase of swallowing could not be objectively assessed. To date, only videofluoroscopy has been used to detect silent aspiration. This investigation assessed the aspiration status of 400 consecutive, at risk subjects by fiberoptic endoscopic evaluation of swallowing (FEES). Our study demonstrated that 175 of 400 (44%) subjects were without aspiration, 115 of 400 (29%) exhibited aspiration with a cough reflex, and 110 of 400 (28%) aspirated silently. No significant differences were observed for age or gender and aspiration status. The FEES, done at bedside, avoids irradiation exposure, is repeatable as often as necessary, uses regular food, can be videotaped for review, and is a patient-friendly method of identifying silent aspiration.

Detection of choledocholithiasis: comparison of unenhanced helical CT and endoscopic retrograde cholangiopancreatography

PURPOSE

To compare unenhanced helical computed tomography (CT) and endoscopic retrograde cholangiopancreatography (ERCP) in the detection of common bile duct calculi.

MATERIALS AND METHODS

Within 13 months, 51 patients (aged 18-94 years) with clinically suspected choledocholithiasis underwent unenhanced helical CT immediately before undergoing ERCP. CT scans were evaluated for the presence of bile duct stones, ampullary stones, the gallbladder and gallbladder stones, intrahepatic biliary dilatation, and the size of the bile duct at the porta hepatis and in the pancreatic head. ERCP images were evaluated for the presence of bile duct or ampullary stones, as well as for biliary dilatation.

RESULTS

Unenhanced helical CT depicted common bile duct stones in 15 of 17 patients found to have stones at ERCP. Three patients had stones impacted at the ampulla, all of which were detected with CT. In addition, there was one false-positive finding at CT. CT had a sensitivity of 88%, a specificity of 97%, and an accuracy of 94% in the diagnosis of common bile duct stones.

CONCLUSION

Unenhanced helical CT is useful for evaluating suspected choledocholithiasis.

Differentiation of achalasia from pseudoachalasia by computed tomography

OBJECTIVES

The purpose of this study was to determine the computed tomography (CT) findings in idiopathic achalasia and in the pseudoachalasia of malignancy.

METHODS

We identified 12 patients with the manometric diagnosis of achalasia who also had CT scans available for review: eight had idiopathic achalasia, and four had pseudoachalasia. As controls, we selected nine patients with endoscopically obvious esophageal cancer who also had CT scans. The CT scans were blindly reviewed to determine esophageal wall thickness, symmetry of the esophageal wall, presence of esophageal dilation or mass, and a radiological diagnosis.

RESULTS

Six of the eight patients with achalasia had a dilated esophagus. Five had symmetric wall thickening >5 mm (range 7-10 mm) at the gastroesophageal junction. One patient with a 10-mm wall thickening was incorrectly diagnosed with a mass. All others were correctly diagnosed with achalasia. Three of the four patients with pseudoachalasia had esophageal dilation. Two had an obvious esophageal mass. The other two were given an indefinite diagnosis: one had asymmetric wall thickening (11 mm) at the gastroesophageal junction, and the other had symmetric thickening of 18 mm. Eight of the nine patients with obvious esophageal cancer had a mass on CT; the other patient had asymmetric wall thickening of 6 mm at the gastroesophageal junction and was given an indefinite diagnosis.

CONCLUSIONS

Most achalasia patients have CT findings of esophageal dilation and mild, symmetric wall thickening. Therefore, symmetric esophageal wall thickening (<10 mm) should not dissuade one from the diagnosis of achalasia. Most pseudoachalasia patients have CT findings of esophageal dilation, more marked and/or asymmetric wall thickening, or mass. In this group, asymmetric or marked thickening (>10 mm) indicated pseudoachalasia. Therefore, CT can be helpful in differentiating between achalasia and the pseudoachalasia of malignancy.

Effect of occlusion of a tracheotomy tube on aspiration

The purpose of the present study was to investigate the effect of occlusion of a tracheotomy tube on aspiration utilizing fluoroscopy. Twenty consecutive tracheotomized patients referred for a modified barium swallow were included. Selection criteria were ability to tolerate tracheotomy tube occlusion during the modified barium swallow procedure, no surgery of the upper aerodigestive tract except tracheotomy, and no history of oropharyngeal cancer or stroke. There was 100% agreement among 3 independent reviewers on ratings of the presence or absence of aspiration. It was found that the occlusion status of the tracheotomy tube did not influence the prevalence of aspiration. Nine of 10 (90%) subjects who exhibited aspiration were over 65 years of age (mean = 72 years 2 months). No trends were observed for bolus consistency, type of tracheotomy tube, or presence/absence of a nasogastric tube and ratings of aspiration.

Pseudotumor of the pancreas associated with retroperitoneal fibrosis: a dramatic response to corticosteroid therapy

A 69-yr-old man with a past medical history of aortic aneurysm and retroperitoneal fibrosis presented with obstructive jaundice and radiographic features suggesting sclerosing cholangitis and malignancy of the head of the pancreas. A presumptive diagnosis of chronic periaortitis was made, and a dramatic response to corticosteroid therapy was subsequently observed. The clinical course of seven additional patients with pseudotumor of the pancreas associated with retroperitoneal fibrosis is also reviewed; three of those patients also responded favorably to corticosteroid treatment.

Vascular compression of the esophagus: a manometric and radiologic study

This study was undertaken to determine the prevalence of vascular compression in manometric tracings and to determine whether these findings had any clinical significance. Vascular compression, defined as a localized area of elevated intraesophageal resting pressure > 4 mm Hg with superimposed cyclic pressure spikes with a frequency of 60-100/min, was noted in 55 of 241 consecutive tracings. The groups with and without vascular compression were similar with regard to mean age, sex, and prevalence of dysphagia. Radiographs were available for 29 of the 55 and showed compression in 18, but there was no relationship with the manometric findings, except for a trend towards finding a positive esophagogram with amplitudes > 16 mm Hg. Eleven tracings showed absent "relaxation" of this elevation of pressure in response to swallows, and five of six available esophagograms showed a corresponding area of compression. We conclude that manometric evidence of vascular compression is common and generally has no clear relationship with esophagographic findings or dysphagia. However, the combined findings of marked increases in pressure and absence of relaxation in response to swallows may indicate evidence for a vascular cause of dysphagia.

Instrumental esophageal perforation: chest film findings

The aim of this study was to evaluate plain film findings of the chest in instrumental esophageal perforation. We hypothesized that such "clean" perforations, often detected early, would be associated with a low frequency of abnormal plain film findings. Fifteen patients with instrumental esophageal perforation were identified, and their records and radiographs were reviewed. Twelve (80%) of the patients had abnormalities suggestive of perforation. The most common (60%) abnormality seen was pneumomediastinum. The second most common (33%) finding was a density adjacent to the descending aorta in the left cardiophrenic angle, resulting in loss of contour of the descending aorta at the level of the left diaphragm. We concluded that plain films, even when taken shortly after instrumentation, provide useful information regarding the presence of esophageal perforation.

Acute jejunoileitis. A distinct entity?

A 44-year-old man with acute jejunoileitis of unknown etiology developed small bowel obstruction. Intermittent abdominal pain, bloody diarrhea, ascites, and leukocytosis were prominent features. All stool cultures were negative. On steroid treatment, symptoms and radiographic features completely resolved. We suggest, in agreement with an earlier report, that acute jejunoileitis may be regarded as a distinct clinical entity.

Pancreatic pseudotumors associated with multifocal idiopathic fibrosclerosis

Two patients with multifocal idiopathic fibrosclerosis and sclerosing cholangitis developed biliary obstruction due to a fibrotic pancreatic pseudotumor. The masslike fibrosis mimicked pancreatic carcinoma on sonography and cholangio-pancreatography. In one patient sonography was successfully used to assess the response of the pseudotumor to corticosteroid therapy.

Of cholescintigraphy, sonography, and great bears. A view on modern biliary imaging

We review the discrepancies and the reasons for them, in two articles in this issue of the Journal to conclude that clinical findings hold the key to selection of the proper imaging test in biliary obstruction. Cholescintigraphy is a more rewarding approach in detecting low grade obstruction, as by common duct stones, whereas in the patient with prolonged painless jaundice, and the high likelihood of a malignancy, computed tomography or ultrasound will yield the best results. Because of the potential for noninvasive imaging to miss choledocholithiasis and because of ever increasing therapeutic options, direct cholangiography will continue to be the mainstay in definition evaluation of the biliary tract.

Gallbladder perforation. An imaging analysis

We evaluated the radiologic studies of 23 patients with surgically or autopsy-documented gallbladder perforation. Extravasation was shown by cholescintigraphy and cholangiography in seven patients and corresponded to free perforation or large pericholecystic loculation. In 16 patients, ultrasonography and computed tomography detected fluid and abscesses outside the gallbladder ranging from 1 to 2 mm pericholecystic fluid collections to large phlegmonous masses. A right, upper-quadrant mass on plain films and scattered calcification in this area suggested perforation. Gallbladder perforation could be diagnosed or suspected preoperatively in ten patients and antemortem in 22 of 23 individuals. This rate of recognition, higher than previously reported, may be ascribed in part to improvements in biliary imaging.

Sclerosing cholangitis from intraarterial floxuridine

The development of biliary strictures simulating sclerosing cholangitis is now well-known. We report a patient undergoing intraarterial chemotherapy for metastatic colon cancer of the liver in whom segmental intrahepatic biliary strictures occurred remote from known metastases. The patient remains alive 3-4 years after documented liver metastases with severe progressive portal hypertension, hypersplenism, and fat malabsorption. A table of cases so far reported is given.

Perforation of distal esophagus with lesser sac extension: CT demonstration

Two cases of esophageal perforation with abdominal extension are described. Radiographic and clinical aspects are discussed with the emphasis on CT as the modality of choice for demonstrating the location and extent of extraesophageal involvement.

Intraluminal meniscoid ulcer in the colon: an unusual sign of malignancy

An unusual sign of malignancy in the colon is described, consisting of an intraluminal lenticular ulcer surrounded by a meniscoid lucency of tumor. This constellation of findings was first described by Carman as a specific indicator of gastric malignancy. An aggressive ulcerating lesion with these characteristics, while rare in the colon, raises the suspicion of carcinoma.

CT demonstration of gastrointestinal involvement in Henoch-Schonlein syndrome

The CT appearance of gastrointestinal involvement in Henoch-Schonlein syndrome is described. The protean manifestations of this disorder are easily confused both clinically and radiographically with those of many other conditions. Mural thickening, thickened folds, ulceration, and spasm are seen radiographically. The CT appearance of segmental mural thickening and luminal narrowing correlates well with the abnormalities seen on the small-bowel series and upper endoscopy.

Postcholecystectomy syndrome: evaluation using biliary scintigraphy and endoscopic retrograde cholangiopancreatography

We prospectively studied 30 patients with postcholecystectomy syndrome to determine the efficacy of biliary scintigraphy in the detection of stenosis of the sphincter of Oddi. All patients underwent endoscopic retrograde cholangiopancreatography (ERCP). Biliary scintigraphy disclosed stenosis of the sphincter by agreement with the ERCP or surgical findings in nine (90%) of ten patients and in eight (100%) of eight patients with biliary obstruction from other causes. Retention of activity at 2 hours in visually prominent ducts was the best predictor of abnormal biliary drainage. Biliary scintigraphy is a useful, noninvasive screening test for the detection of postcholecystectomy biliary obstruction.

Toxic dilatation in Crohn disease with CT correlation

We describe the CT appearance of toxic dilatation in a patient with Crohn disease. The CT manifestations of this uncommon but important entity have not been previously described. The involved portion of the colon was mildly dilated and demonstrated pseudopolyp formation. Bowel wall thickening in this segment was minimal as expected in toxic dilatation. Intramural gas was identified representing pneumatosis intestinalis, an ominous sign in this condition.

Hepatobiliary scintigraphy and sonography in early biliary obstruction

The authors examined 139 patients thought to have early, partial, or intermittent biliary obstruction, using sonography, hepatobiliary scintigraphy, and in selected cases contrast cholangiography. Of 125 patients with a well-established final diagnosis, sonography and scintigraphy disagreed in 29 (23%). Scintigraphy revealed early or low-grade obstruction in 13 patients who had no evidence of dilated ductules, while 7 patients with dilatation from prior stone passage or biliary surgery showed normal clearance. The authors conclude that in a preselected population in whom early or low-grade biliary obstruction may be present, disagreement between sonography and scintigraphy is not rare, and the absence of sonographically detectable dilatation does not exclude obstruction.

Strategy for the use of biliary scintigraphy in non-iatrogenic biliary trauma

Biliary scintigraphy was used to examine 21 patients who had suspected non-iatrogenic biliary trauma. Seven patients (33%) had scintigraphic evidence of biliary leakage. Ultimately, surgical biliary repair was required for only three of these patients. Visualization of the gallbladder did not occur in eight trauma patients, but only one patient was shown to have cholecystitis. In this series, 16 patients had Tc-99m sulfur colloid scans that offered no significant advantage over cholescintigraphy in the detection of hepatic parenchymal defects. Biliary scintigraphy provides clinically useful information in cases both of blunt and penetrating trauma.

Ultrasonography and hepatobiliary scintigraphy in the assessment of biliary-enteric anastomoses

Twenty-three patients with surgical diversion of the biliary tract were serially studied with ultrasonography and hepatobiliary scintigraphy using 99mTc-HIDA or 99mTc-disofenin. Refluxed biliary air resulted in nondiagnostic sonograms in 14% of cases. Persistent postoperative dilatation was present in five patients (22%). Scintigraphy allowed differentiation of biliary dilatation with obstruction from nonobstructed dilatation. By coordinating the noninvasive imaging results, those patients requiring study using direct injection of contrast material may be selected.

Diagnostic utility of cholescintigraphy and ultrasonography in acute cholecystitis

When faced with a patient with possible acute cholecystitis, technetium-99m-HIDA scintigraphy should be the primary diagnostic procedure performed. If scintigraphy reveals a normal gallbladder, acute cholecystitis is excluded. If the scintigram fails to visualize the gallbladder, ultrasonography is deemed advisable to exclude potential false-positive scintigrams and confirm the presence of cholelithiasis.

Disparate dilatation of the intrahepatic and extrahepatic bile ducts in surgical jaundice

Intrahepatic biliary dilatation on ultrasound has been reported as an early sign of biliary obstruction. This paper reports 12 patients with extrahepatic biliary obstruction in whome the extrahepatic biliary system was increased in caliber despite a normal appearance of the intrahepatic ducts. The bile ducts in all of these patients were evaluated with ultrasound and percutaneous transhepatic cholangiography. Computed tomography was performed in one case. The causes of obstructive jaundice included stricture, choledocholithiasis, and neoplasm. The common bile duct provides a sensitive indicator of biliary obstruction, and its demonstration by noninvasive or invasive means is mandatory even when the intrahepatic ducts appear to be normal.

Ultrasound demonstration of anicteric dilatation of the biliary tree

This report presents eight patients with dilatation of the biliary tree, six of whom had no clinical or laboratory evidence of biliary tract disease except for elevated levels of serum alkaline phosphatase. In two patients, dilatation was caused by obstruction of only one hepatic duct; in three, it was caused by a pancreatic tumor; and in three, it was associated with gallstones which exercised a ball-valve effect, producing intermittent obstruction. The elevation of the alkaline phosphatase level in six of these patients suggests that it is a more sensitive indicator of biliary tract obstruction than the serum bilirubin level is. The recognition of biliary dilatation in one or both lobes of the liver should lead to a careful examination, with ultrasound or another modality, of the porta hepatis, common bile duct, and pancreas.

Diagnostic imaging procedures in acute pancreatitis. Comparison of ultrasound, intravenous cholangiography, and oral cholecystography

To evaluate the role of intravenous cholangiography (IVC), ultrasound andoral cholecystography in the diagnosis of gallstone pancreatitis, 20 patients with acute pancreatitis were studied during the first three days of an attack. The IVC successfully demonstrated the common bile duct and gallbladder in 17 (85%) 20 patients. The ultrasound studies showed the gallbladder in all 18 patients in whom the gallbladder was present. The common duct was not seen by ultrasound in any patient and the pancreas was abnormal in all patients. In the three patients with gallbladder stones these were identified on both IVC and ultrasound. Common duct stones in three patients were seen only by IVC (two of these patients had concurrent gallbladder stones and one after cholecystectomy). Oral cholecystography was of limited usefulness, although the 50% visualization rate was higher than the literature suggests.

Acute colitis related to penicillin and penicillin derivatives

5 cases of acute transient colitis associated with the ingestion of ampicillin, an ampicillin derivative, and penicillin are discussed. The clinical presentation, course, and radiographic and sigmoidoscopic findings are distinct from those in pseudomembranous colitis. The colonic changes may be related to an allergic reaction in the intestine which results primarily in transient ischaemia. The presenting symptom is blood diarrhoea, and barium enema is the most productive diagnostic examination.

Radiology of the gastrointestinal abnormalities seen in patients with adult hepatorenal polycystic disease

A review of 97 patients with adult hepatorenal polycystic disease (AHRPD) revealed a significant number of patients with gastrointestinal symptoms as the initial or primary manifestation of their disease. The typical appearance of the gastrointestinal barium examinations is presented.

Borderlands in the diagnosis of regional enteritis: trends in overdiagnosis and value of therapeutic trial

Our regional experience in the state of Connecticut indicates that Crohn's disease is being overdiagnosed. Six patients with disorders mimicking regional enteritis are presented, one of whom had an atypical clinical course and the remainder had atypical therapeutic responses. The radiologist should be aware of clinical responses and make reassessments if necessary, in order not to overlook surgically treatable conditions.

The protean gastrointestinal manifestations of metastatic breast carcinoma

Metastatic breast carcinoma commonly remains silent for many years following initial diagnosis and mastectomy, and then appears as metastases at various locations. Gastrointestinal involvement is not uncommon and includes any site along the whole length of the gut, the liver, and the biliary tree; it occasionally simulates other diseases and causes difficulty in diagnosis. The radiographic features and differential diagnoses are discussed.

Wandering spleen--the radiological and clinical spectrum

Eight cases of wandering spleen demonstrate that this rare entity has a characteristic constellation of findings which, though nonspecific, are highly suggestive of the diagnosis. Angiography or isotopic imaging specific for the spleen confirms the diagnosis. Asymptomatic patients may be carefully observed, with the institution of splenectomy should signs of torsion develop.