Laxative-free CT colonography

OBJECTIVES

The aim of this study was to determine if the introduction of faecal tagging to CT colonography (CTC) made the examination easier to tolerate or reduced the number of false-positives.

METHODS

Our department changed bowel preparation for CT colonography from Picolax (Ferring Pharmaceuticals Ltd, London, UK) to Gastrografin (Bracco Diagnostics Inc, Princeton, NJ) only with a modified diet. Questionnaires were given to a subgroup of patients within these cohorts. The numbers of false-positives were compared between two cohorts before and after this change. false-positives were defined as lesions reported on CT that were not confirmed by subsequent endoscopic examination. Polyps were matched if they were in the same or adjacent segments, and were within 5 mm of the reported size.

RESULTS

412 patients were identified from the Picolax cohort, and 116 from the Gastrografin cohort. 62 patients in each group completed questionnaires. Gastrografin produced less diarrhoea; 34% had five or more bowel motions in the previous day and night, compared with 77% for Picolax (p<0.001), although more patients found drinking it unpleasant compared with Picolax (85% reported drinking Picolax as "easy" vs 61% for Gastrografin; p=0.002). Picolax produced more non-diagnostic examinations, although this difference was not statistically significant. There was not a significant reduction in the numbers of false-positives (2 out of 112 for Gastrografin group, 14 out of 389 for the Picolax group; p=0.54).

CONCLUSION

Switching from Picolax to Gastrografin as a CTC preparation technique produced less diarrhoea, but did not reduce the number of false-positives.

Rectal intussusception and unexplained faecal incontinence: findings of a proctographic study

BACKGROUND

The aetiology of faecal incontinence is multifactorial, yet there remains an approach to assessment and treatment that focusses on the sphincter. Rectal intussusception (RI) is underdiagnosed and manifests primarily as obstructed defecation. Yet greater than 50% of these patients admit to faecal incontinence on closer questioning. We aimed to evaluate the incidence of RI at evacuation proctography selectively undertaken in the evaluation of patients with faecal incontinence.

METHOD

Patients with faecal incontinence seen in a pelvic floor clinic were evaluated with anorectal physiology and ultrasound. Where the faecal incontinence was not fully explained by physiology and ultrasound, evacuation proctography was undertaken. Studies were classified as 'normal', 'low-grade RI' (recto-rectal), 'high-grade RI' (recto-anal) or 'anismus'.

RESULTS

Forty patients underwent evacuation proctography (33 women, 83%). Median age was 63 years (range 34-77 years). Seven patients (17%) had a normal proctogram. Three (8%) had recto-rectal RI. Twenty-five (63%) demonstrated recto-anal RI. Five patients (12%) had anismus.

CONCLUSION

Recto-anal intussusception is common in patients undergoing selective evacuation proctography for investigation of faecal incontinence. The role of recto-anal intussusception in the multifactorial aetiology of faecal incontinence has been largely overlooked. Evacuation proctography should be considered as part of routine work-up of patients with faecal incontinence.

Radiological detection of post-oesophagectomy anastomotic leak - a comparison between multidetector CT and fluoroscopy

The purpose of this study was to directly compare CT with fluoroscopy for the diagnosis of occult anastomotic leak following oesophagectomy. Patients undergoing oesophagectomy and gastric conduit formation for the treatment of oesophageal cancer were eligible for inclusion. Imaging was performed 6-8 days post-operatively. Patients underwent multislice CT examination of the chest and abdomen with a bolus of oral contrast, followed by fluoroscopic water-soluble contrast swallow (with subsequent use of barium if this was normal). The studies were reviewed by a consultant radiologist, who was blinded to the results of the other modality. Images were reported as showing "no leak", "possible leak" or "definite leak". The presence of mediastinal gas or fluid or extraluminal contrast at CT was recorded. The clinical outcome after reinstituition of oral intake was used as a reference standard. Patient preference for modality was recorded. 52 patients were recruited. Four were found to have leak on CT and fluoroscopy. 11 had possible leak at CT, but normal fluoroscopy: 2 of these had a leak confirmed later, whereas 9 had no leak. 37 had normal CT and fluoroscopy findings, and remained clinically well. The sensitivity, specificity, positive and negative predictive values were 100%, 80%, 40% and 100%, respectively, for CT, and 67%, 100%, 100% and 96%, respectively, for fluoroscopy. The positive predictive value of mediastinal air, air/fluid and extraluminal contrast were 25%, 75% and 50%, respectively. 35 patients found CT more tolerable. In conclusion, CT was better tolerated and more sensitive but less specific than fluoroscopy for detecting occult anastomotic leak.

Imaging following surgery for oesophageal cancer

The incidence of oesophageal malignancy is increasing in the UK. Surgical management with oesophagectomy is determined by tumour location, stage and extent of lymphadenectomy,and is also dependent on patient age and co-morbidity. Surgery is associated with considerable postoperative morbidity and mortalities of up to 7%. The indications for imaging and findings in both the immediate and delayed postoperative periods are discussed.

Pitfalls in the clinical diagnosis of vertebral fractures: a case series in which posterior midline tenderness was absent

OBJECTIVE

There is widespread belief among doctors that posterior midline tenderness is virtually a prerequisite for spinal fracture in alert, sober patients without any painful distracting injury or neurological deficit. This paper examines and challenges this belief.

METHODS AND RESULTS

We present three patients in whom significant thoracic and lumbar vertebral fractures were missed, or were thought to be "old", because of lack of posterior midline tenderness. We also present two further patients, one with a lumbar spine fracture and one with a cervical spine fracture, in whom posterior midline tenderness was absent but in whom the correct diagnosis was made. All these patients were sober and fully alert and none had a neurological deficit or a painful distracting injury.

CONCLUSION

The absence of posterior midline tenderness does not exclude significant spinal injury. We suggest that patients should satisfy both the Canadian and British guidelines before it is decided that imaging of the cervical spine is unnecessary.

Human brain wave activity during exposure to radiofrequency field emissions from mobile phones

The aim of this study was to determine whether there is an effect of mobile phone electromagnetic field emissions on the human electroencephalograph (EEG). EEG recordings from ten awake subjects were taken during exposure to radiofrequency (RF) emissions from a mobile phone positioned behind the head. Two experimental trials were conducted. In the first trial, RF exposures were generated by a GSM mobile phone with the speaker disabled and configured to transmit at full-radiated power. During the second trial, exposures were generated by a non-modified GSM mobile phone in active standby mode. For each trial, subjects were exposed in five minute intervals to a randomized, interrupted sequence of five active and five sham exposures. The experiment was conducted under single-blind conditions. The average EEG band power in active exposure recordings was compared to corresponding sham recordings. Statistical tests indicated significant difference in the full-power mode trial within the EEG alpha (8-13 Hz) and beta (13-32 Hz) bands. A subsequent statistical analysis of median spectral power in discrete EEG rhythms revealed significant differences in 7 of the 32 distinct frequencies overall. In conclusion, the results of this study lend support to EEG effects from mobile phones activated in talk-mode.

Perforation of the oesophagus and aorta after eating fish: an unusual cause of chest pain

This report describes perforation of the oesophagus after eating fish complicated by perforation of the aorta six days later. The patient had not knowingly swallowed a fish bone. Aorto-oesophageal fistula is almost universally fatal. In the case described here, the fistula was demonstrated on contrast computed tomography before surgery, thus informing surgical management. The patient is the eighth reported survivor.

Primary yolk sac tumour of the liver in adulthood

Primary yolk sac tumour of the liver is exceedingly rare. A 28 year old woman presented with a cystic liver mass and a markedly raised serum alpha-fetoprotein concentration. She underwent a partial hepatectomy for a suspected hepatocellular carcinoma but histological examination of the tumour revealed the classical morphological and immunohistochemical features of a yolk sac tumour. There was no evidence of an extrahepatic primary source. Review of this case, together with the six previously reported adult cases of primary yolk sac tumours of the liver, revealed several features of the tumour that may aid differentiation from hepatocellular carcinoma, with potential therapeutic implications.

Technical report: perirectal abscess drainage--a simple modification in technique using a vascular sheath

Two patients with pelvic abscesses underwent fluoroscopic guided transrectal catheter drainage using a simple modification in standard technique. A 9F vascular sheath allows contrast to be instilled through the side port and the seal avoids any leakage back through the sheath. It also provides a safe, quick and precise needle puncture at the selected site.

Magnetic resonance imaging in macromelia and macrodactyly

We report five cases presenting with soft tissue and bone overgrowth that demonstrate the ability of MRI to establish a diagnosis in the absence of specific clinical features. Disorders included macrodystrophia lipomatosa, angiolipomatosis, Klippel-Trenaunay-Weber syndrome, blue rubber bleb naevus syndrome and one case of segmental limited hypertrophy. The MRI appearances, and other radiological features of these conditions are discussed. MRI is recommended in all cases of macrodystrophy when the clinical features and plain film findings are indeterminate.

Case report: coincident granular cell tumour of the breast with invasive ductal carcinoma

Granular cell tumours of the breast are rare lesions which are almost always benign. They are of interest because their clinical, radiological and pathological appearances often closely resemble those of malignancy. A case is described in which screening mammography in an asymptomatic woman led to the diagnosis of simultaneous invasive intraductal carcinoma in one breast and benign granular cell tumour in the other. Granular cell tumour of the breast coincident with other breast tumours is very rarely described and an association with breast carcinoma is unknown.

Visceral slide for intraperitoneal adhesions? A prospective study in 48 patients with surgical correlation

Bowel perforation in patients undergoing laparoscopic surgery is an uncommon but serious complication. Bowel adherent to the anterior abdominal wall due to adhesions is considered a particular risk. It has been suggested that transabdominal ultrasound can reliably predict the presence of intraperitoneal adhesions. Normal bowel excursions (visceral slide) in 15 volunteers with no history of surgery or peritonitis and in 48 patients undergoing abdominal surgery were evaluated. Visceral slide during spontaneous respiration (SRSL) with manual compression (MCSL) and exaggerated respiration (ESL) was assessed in all 4 quadrants. Adhesions were found in 43 quadrants (12 in the RUQ, 6 in the LUQ, 14 in the RIF, and 11 in the LIF) in 21 patients at surgery. Reduced SRSL detected fibrous adhesions in 6 of 15 quadrants, but only 3 of 28 fibrinous adhesions, with an overall sensitivity of 21%, specificity of 94%, and accuracy of 76%. MCSL detected 9 of 15 fibrous and 9 of 28 fibrinous adhesions, with an overall sensitivity of 42%, specificity of 73.5%, and accuracy of 62%. ESL detected 6 of 15 fibrous and 3 of 28 fibrinous adhesions, with an overall sensitivity of 20%, specificity of 76%, and accuracy of 63%. Preliminary results suggest that ultrasound can detect adhesions preoperatively, but the overall sensitivity is poor and the number of false-positives and false-negatives make it unreliable for routine use.

Simple method of orientating breast biopsies following hook-wire or ultrasonographic localization of impalpable mammographic abnormalities

Localization of impalpable breast lesions with fine wires is standard practice and several variations of the hook-wire device have been described1. More recently ultra-sonography2 has been used as an accurate and rapid method of preoperative localization of mass lesions. Accurate biopsy of all clinically impalpable suspicious mammographic abnormalities is essential and complete excision is important in those patients with malignant disease3. Having performed a localization biopsy, precise specimen orientation allows further excision if original margins are involved. A simple and inexpensive method of orientating tissue specimens following excision biopsy is described.

Case report: intestinal perforation--an unusual complication of endoscopic biliary stenting

The endoscopic placement of stents to decompress biliary obstruction is accepted practice in the management of malignant biliary strictures. In our patient, a 73-year-old man with a presumed malignant common hepatic duct stricture, palliation of his obstructive jaundice has been achieved. However, his clinical course was complicated by a colonic perforation--a previously unreported complication of distal stent migration.

Patient management following uncomplicated elective gastrointestinal operations

The management of patients after uncomplicated elective gastrointestinal operations is frequently left to junior members of the surgical team once they have learnt their seniors' regimens. The use of nasogastric (N/G) tubes, the volume of intravenous (IV) fluid replacement and the reintroduction of oral fluids and solids are topics not generally covered in the surgical textbooks and so are learnt in hospital. A postal survey of all consultant general surgeons in Scotland was conducted to assess the variations in management of patients after cholecystectomy, right haemicolectomy and sigmoid colectomy. A completed questionnaire was received from 111 (81%) of the surgeons circulated. As might be expected, patient management varied widely from surgeon to surgeon, and from unit to unit. There would appear to be a need for prospective studies in this area of patient management. This may indicate that the use of N/G tubes could be further reduced and that oral fluids and solids could be reintroduced sooner after operation with improved patient comfort and reduced hospital stay, yet without detriment to patient care.