Ultrasonographic evaluation of piecemeal deglutition in normal adults.

OBJECTIVES: To evaluate the range of multiple swallowing in normal subjects by ultrasonography. METHODS: Twenty-two normal subjects swallowed 5 or 10 ml of tap water or a semisolid meal. RESULTS: With water multiple swallows were seen in 41% of the subjects examined and was related to the volume of the bolus:18% of the cases were 5 ml and 36% were 10 ml. Sixty-eight percent of subjects had multiple swallows with semisolid boluses. CONCLUSION: These results differ from those reported with videofluoroscopy of modified barium swallowing. Ultrasonography should be used in future studies of normal and pathological oral swallowing.

Case report: identification of the transverse mesocolon and root of small bowel mesentery; a new sign of pneumoperitoneum.

A new sign of pneumoperitoneum was observed in a patient with perforation of the ascending colon. The presence of free air in the peritoneal cavity allowed identification of the transverse mesocolon and the root of the small bowel mesentery on plain abdominal radiographs obtained in the supine and in the prone position. This sign may be an aid in the diagnosis of pneumoperitoneum.

CT and anal endosonography in the evaluation of electrically stimulated neoanal sphincter: a preliminary report.

We report a preliminary experience concerning the postoperative assessment of three patients who underwent gracilis neosphincter operation for severe fecal incontinence and were studied by computed tomography and anal endosonography soon after gracilis transposition and later after 6-8 weeks of neuromuscular training. Morphologic assessment was correlated with physiologic testing (manometry). Continence was satisfactorily improved in all patients. Both imaging techniques demonstrated the anatomy of the transposed muscle. Computed tomography also assessed lead placement onto the gracilis nerve root and the completeness of muscle transposition around the anal canal. Anal endosonography provided a more accurate assessment of the relation between the neosphincter and residual external sphincter.

[Hand injuries due to fireworks explosion]. / I traumi della mano da scoppio di petardo.

Two different series of patients with burst injuries of the hand were retrospectively reviewed: one series included 23 men, 15-55 years old, referred to the emergency department for the first-instance assessment of injuries of the right hand (13 patients) and left hand (10 patients). The other series included 44 patients (42 men and 2 women, aged 7-61 years) referred to our department for second-instance examinations: the latter patients had burst injuries involving only the hands in 43 cases and both the hand and the foot in one case. We report the radiologic patterns of traumatic bone injuries (fractures and amputations) and of musculotendinous and cutaneous injuries and discuss their mechanisms and pathogenesis. The two series were compared and the results follow: in both series the right hand was more frequently involved, metacarpal bones were most often fractured and phalanges most often amputated. In the first series, in the right hand the carpal bones were involved in one patient only, the 2nd and 3rd metacarpal bones were most frequently fractured and the 2nd finger was most frequently involved. In the left hand, the carpal bones were never affected, the 1st metacarpal bone was most often amputated and the 5th metacarpal bone most often fractured; the 2nd finger was most frequently involved. In the second series, in the right hand, the 1st metacarpal bone was most frequently fractured and the 2nd metacarpal bone most often amputated; the 2nd finger was most frequently involved. In the left hand, the 4th metacarpal bone was most frequently fractured and the 5th metacarpal bone most often amputated. The severity of the above injuries and the extent of tissue damage depend on several factors, including firecracker speed, shape, size, weight and characteristics. Radiologic exams are very useful for the accurate study of these traumatic injuries, providing indirect information about musculotendinous and cutaneous involvement. Prompted by the relative lack of information on the management of these injuries, we suggest that radiologic exams be quickly performed to help choose the most appropriate surgical approach for best cosmetic and functional results.

["Uncompensated" small bowel obstruction in adults. Ultrasonographic findings of free fluid between loops and its prognostic value]. / Ileo meccanico "scompensato" dell'intestino tenue nell'adulto. Rilievo ecografico di liquido libero tra le anse e suo significato prognostico.

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.

[Endoanal ultrasonography, defecography, and enema of the colon in the radiologic study of incontinence]. / Ecografia endoanale, defecografia e clisma del colon nello studio radiologico dell'incontinenza.

In the last 3 years, the authors examined 564 patients with disturbed anorectal function. Of 41 incontinent subject in this series, 30 were retrospectively analyzed to assess the diagnostic contribution of double contrast barium enema, defecography and endoanal sonography. The authors propose a classification of fecal incontinence based on imaging findings: indeed, rectal incontinence can be distinguished from pelvic and sphincteral incontinence. Large bowel enema and defecography are the examinations of choice if rectal incontinence is suspected on the basis of clinical history and possible endoscopic, manometric and electromyographic findings. Defecography is suggested if pelvic incontinence is suspected, while anal endosonography is the exam of choice in case of suspected sphincteral incontinence. Especially thanks to the recent availability of the latter technique, today radiologists can directly visualize the anal sphincteral apparatus and its lesions, yielding objective evidence of this type of incontinence too. The authors report on both limitations and indications of each diagnostic method and conclude by stressing the fundamental role diagnostic imaging plays today in the study of this disorder.

Physiology of oral swallowing studied by ultrasonography.

The aim of the study was to identify a number of sonographic landmarks in the evaluation of the oral phase of swallowing. Forty non-dysphagic adults (average age 38 years) and 20 normal bottle-fed newborns (average age 13 days) were submitted to videorecorded sonographic examination using two types of transducers (5 and 7.5 MHz). The adults were asked to swallow a 20 ml bolus of water and the newborns were examined while sucking from a bottle containing milk. Preliminary transverse scans of the neck were obtained to evaluate laryngeal movements during swallowing. The mouth was examined through the submental window using sagittal and coronal scans. In the newborn, additional transbuccal scans were employed. In both adults and newborns highly significant and reproducible images of single-element motor events involved in swallowing were obtained. Normal sonographic images of the oral stage of deglutition form the baseline from which abnormal patterns may then be recognized.

[Videoproctography in the study of rectal intussusception. The authors' own experience]. / La videoproctografia nello studio dell'intussuscezione rettale. Esperienza personale.

Videoproctography has proved to be a useful diagnostic technique to investigate anorectal disorders; it can provide morphological and functional information which no other diagnostic method yields. From a series of 898 videoproctographs, the findings of 117 patients with rectal intussusception were retrospectively reviewed. The most common symptoms were an incomplete emptying feeling (93% of cases), obstructed defecation (78%), and a feeling of upright rectal weighting (71%). Of the three known types of rectal intussusception, the most common type was distal intussusception (44%), followed by the rectoanal type (38%) and finally by the proximal type (19%). The three types of intussusception were frequently (42%) associated with other disorders of rectal ampulla and especially with rectocele (15%), mucosal prolapse (8%), and descending perineum syndrome (12%); they had different clinical correlations and proctographic patterns and could be recognized in different defecation phases. In our personal experience, proctography with videorecording was a useful diagnostic tool in the dynamic assessment of this morphofunctional disorder which represents one of its major indications.

[Radiology of chronic intestinal insufficiency]. / Radiologia dell'insufficienza intestinale cronica.

Impaired intestinal function, negatively affecting food digestion and absorption, is called chronic intestinal failure (CIF). The clinical conditions leading to CIF are: fistulas, wide resections and severe damage to small bowel, and chronic intestinal stasis. In the etiology of CIF, the most frequent conditions are: Crohn's disease, postoperative peptic ulcer, mesenteric arteriopathy, radiation enteropathy, acute pancreatitis, jejunoileal diverticulosis and intestinal pseudo-obstruction. The radiologic approach to CIF can aim at: 1) diagnosing the disease and the clinical conditions causing it; 2) morphometric analysis: lesion spread, length of the extant normal small bowel and adaptive changes. Digestive tube radiology has always been considered a fundamental investigation technique to study malabsorption. Double contrast enema has increased the diagnostic capabilities of radiology. Moreover, double contrast enema allows the extraoperative evaluation, in vivo, of a new anatomic feature--i.e., intestinal length--which is a valuable sign for an exhaustive interpretation of CIF, especially of the short bowel syndrome. Thanks to double contrast enema, the changes in the length of mesenteric small bowel can be calculated in vivo (range: 150-430 cm; mean: 291 cm, SD 59). Intestinal length < 150 cm was observed only in resected patients. In 25% of cases, short small bowels were associated with CIF. Such morphometric studies, if applied to clinical practice, may yield valuable information for both diagnosis and prognosis.

[Intestinal tuberculosis. The radiologic aspects of a disease not to be overlooked]. / Considerazioni sulla tubercolosi intestinale. Aspetti radiologici di una malattia da non dimenticare.

Intestinal tuberculosis still exists in the Western world, where it is usually underestimated and often mistaken for Crohn's ileo-colitis or cancer. The authors report the results of 4 cases of intestinal tuberculosis observed between 1983 and 1988. The cases are discussed in the light of the epidemiological data emerging from a review of recent medical literature. The danger is that the disease, which is endemic in Asian and African regions, may spread again in the Western world fostered by intensifying migrations of people and by the spreading of AIDS. According to recent experience, a negative chest film and Mantoux skin-test no longer have a negative predictive value for intestinal tuberculosis. In the radiological differentiation from Crohn's disease it is useful to keep in mind some topographic features of TBC: the systemic non-discontinuous involvement of both sides of ileocecal junctions; the unusual presence of ileal lesions, with no cecal lesions, and localizations below the transverse colon. Useful differential morphological criteria can be: star-like or transverse ring-shaped profile of isolated ulcerations, tubular ileocolic junction with retracted cecum and open valve, and uniformity of lesion in the comprehensive picture of the clinical case.

[Radiologic assessment of extent of ulcerative colitis in acute phase]. / Valutazione radiologica dell'estensione della colite ulcerosa nella fase acuta.

One of the major reference points for both prognosis and treatment of ulcerative colitis is the assessment of its extent. Plain abdominal radiographs were performed on 97 patients previously diagnosed, by means of rectoscopy and histobiopsy, as having acute ulcerative colitis. Within the following 36 hours they underwent either full colonoscopy or colectomy. The extent of colitis was evaluated by means of double-blind radiography. The results were then statistically compared with those obtained from endoscopy or from direct study of surgical colonic specimens. There was agreement between the final X-ray results and the actual extent of ulcerative colitis in 78 of 97 patients (80.4%, r = 0.86). The highest agreement was observed in those patients whose lesions were localized in the rectosigma (81%) and in those with fully extended colitis (90%). The most useful radiological findings in predicting the extent of colic lesions were irregular mucosal profile and thickening of colic wall. The presence of these two signs, together with the flattening or swelling of interhaustral folds and the impossible visualization of the right colon, are invariably suggestive of fully extended colitis. On the contrary, no abnormal findings were present on plain abdominal films in 74% of proctosigmoiditis cases. Plain abdominal radiography seems to be useful for the initial evaluation of acute ulcerative colitis. It allows the early discrimination between diffuse and localized forms, and makes it possible to postpone more invasive and dangerous investigations to a remissive phase of the disease.

Sonographic evaluation of physiologic bolus volume in oral swallowing.

Twenty-two nondysphagic normal subjects were sonographically studied to define the average volume of a physiologic fluid bolus. Several varying volumes (5, 10, 15, and 20 ml) of water were given to assess the average size of the swallowed bolus. At the onset of oral deglutition, when placed between the dorsum of the tongue and the groove of the hard palate, the bolus has an ellipsoidal shape, thus permitting sagittal, axial, and coronal measurements. Our results indicate that swallowed bolus volume rises proportionally to water bolus given up to 15 ml and that the average size of a physiologic fluid bolus is 7 ml.

[The echographic visualization of the lingual bolus. The reference point in a study of dysphagia]. / La visualizzazione ecografica del bolo linguale. Punto di riferimento nello studio delle disfagie.

The videotape recording of the cinefluorographic images obtained with barium swallowing, proved to be very useful in studying pharyngo-esophageal motility. On the contrary, the method failed to be exhaustive in the study of the oral phase of swallowing. In 1983 Shawker et al. were the first authors to suggest the use of US to record tongue motility and the upward movement of hyoid bone. In a previous paper the authors had reported on the value of US videorecording in the dynamic study of oral swallowing, and of lingual bolus development and shape. In the present paper, the authors investigated how frequently the formation of lingual bolus can be recorded by means of US in patients with no dysphagic disorders. Sagittal and transverse scans were acquired in all patients with US units with 5 MHz probes connected to a U-matic videorecorder. In 98% of 50 examined patients, US demonstrated the presence of a lingual bolus in the preparatory phase of oral swallowing. Since lingual bolus formation in the oral phase of swallowing can be considered quite a normal event, the authors believe this finding to be a reliable reference-point in the study of oral swallowing.

[Rehabilitation of oro-pharyngeal dysphagia of neurogenic etiology using radiological examination: preliminary results]. / Riabilitazione della disfagia oro-faringeaad eziologia neurogena guidata dall'indagine radiologica: risultati preliminari.

Dysphagia is more frequently observed in patients with neurologic diseases (stroke, bulbar or pseudo-bulbar syndrome, amyotrophic lateral sclerosis, cranial trauma). Furthermore, the presence of this pathology is obviously more frequently noted in the light of the increase in the length of the human life span. It has become evident that alternative feeding procedures such as the nasogastric tube or gastrostomy may bring about complications and deprive patients of the oral phase of deglutition which plays a leading role in stimulating digestive functions. The Authors report a systematic research on the rehabilitation aspects of neurogenous dysphagia. All the patients studied underwent a neurological examination and oropharyngeal functional evaluation using echo-videorecording of the oral phase of deglutition and fluoro-videorecording of the pharyngeal phase. The data obtained allowed for the selection of five patients considered suitable for the rehabilitation program. One of them had a multi-infarct encephalopathy, two a spastic hemiplegia f.b.c., a fourth a cerebellar syndrome and the last a sequela of meningioma removal of the ponto-cerebellar angle with peripheral paralysis of the right VII, IX, X, XI cranial nerves. This last patient also underwent a crico-pharyngeal myotomy. Therapy consisted in making the patient sensitive to swallowing movements and in training them to assume a compensatory posture as well as functional rehabilitation of the organs involved in deglutition. The first datum emerging from the study is the lack of etiological homogeneity found in the cases treated with evident variability in different deglutition organ impairment, even though there was the common denominator of the dysphagia symptom. With regard to the results obtained, there was a complete resolution in one patient, while in the other four there was such an improvement as to allow the patients a safe autonomous oral assumption of food. The positive results obtained are not only linked to the recovery of damaged organs, but also to the development of compensatory strategies such as the choice of appropriate food consistency and the assumption of postures which protect the respiratory tract from aspiration and favor crico-pharyngeal relaxation.

The plain abdominal film accurately estimates extent of active ulcerative colitis.

The aim of our study was to establish whether plain abdominal film can accurately assess the extent of active ulcerative colitis. Ninety-seven ulcerative colitis patients were studied, in whom the extent of the macroscopic lesion was established either by colonoscopy (n = 75) or by resection (n = 22). Of these, 42 had proctosigmoiditis, 12 left-sided colitis, 12 subtotal colitis, and 31 total colitis. Nine well-tested features were used for the radiological classification of lesion extent. The radiologists were not given any clinical information. Seventy-eight patients (80.4%) were correctly classified by plain abdominal film (r = 0.86); the best concordance was achieved for proctosigmoiditis and total colitis (80.9 and 90.3%, respectively). In total colitis the most reliable radiological features were "irregularity of the mucosal edge" and "increased thickness of the colon wall, " which were present in 74.2 and 67.7%, respectively, of the correctly classified patients. The fourfold combination of these two features with "loss of haustral clefts" and "empty right colon" was present only in patients with total colitis, and at least one of these features was present in all but one of them. Conversely, all nine abnormalities were absent in 73.8% of patients with proctosigmoiditis. In conclusion, plain abdominal film is a reliable tool for judging the extent of lesion in active ulcerative colitis. It seems particularly accurate in total colitis, where, in the acute phases, it is most important to avoid invasive examinations.

[Dynamic study of oro-pharyngeal deglutition]. / Lo studio dinamico della deglutizione oro-faringea.

Oropharyngeal swallowing is too fast and complex a motion for the human eye to seize its various phases and subsequently evaluate morphology and function of the anatomical structures involved. A chronological subdivision of the swallowing act is needed for a step-by-step analysis. Dynamic evaluation of oropharyngeal swallowing by means of fluoroscopic and US videorecording proved to be a reliable method. Echovideorecording allowed tongue movements to be depicted, together with bolus formation and propulsion. Fluorovideorecording (U-matic Sony unit, 25-30 images/sec) demonstrated pharyngeal and esophageal phases. A series of chronological and morphological reference points, which characterize oropharyngeal swallowing, were employed to analyze videorecorded images. Slow-motion mode, "freezed" images, and rewinding allowed an easy and accurate evaluation of swallowing details. Combined chronological and morphological pieces of information allow a comprehensive evaluation of the swallowing act.

[Echography of the oral phase of deglutition]. / L'ecografia nello studio della fase orale della deglutizione.

Neither cineradiography nor videorecording are satisfactory techniques for the dynamic study of the oral phase of deglutition. Therefore, oral swallowing was studied by means of real-time sonography (US) in 20 asymptomatic patients. Both anatomy and motility of the muscles of the mouth and tongue were clearly demonstrated. Real-time US proved thus to allow an accurate and dynamic visualization of the oral phase of deglutition.