Pancreatic somatostatinoma: presentation with recurrent episodes of severe hyperglycaemia and ketoacidosis.

A 47-year-old woman was admitted on four occasions over a four-year period with severe hyperglycaemia associated with marked ketoacidosis. She had weight loss with hepatomegaly and ultrasonography indicated a pancreatic tumour which was shown to be a somatostatinoma. Resection resulted in prolonged survival. The biochemical and morphological features of this rare tumour are presented, and an explanation for the unusual presentation of a somatostatinoma with episodes of ketoacidosis is given.

Major lower intestinal haemorrhage. Angiographic localisation and current management.

Thirty-four patients with major lower intestinal bleeding underwent emergency selective mesenteric angiography during a 6-year period. Angiography identified a bleeding site in 16 patients (47%). Diverticulosis, found in 22 patients (65%), and angiodysplasia, found in 4 (12%), were the most common causes of major colonic bleeding and originated more frequently from the right colon. Eight patients (24%) bled from less common sources. Radiological control of bleeding was unreliable with a significant complication rate. Fourteen of 16 patients with positive angiograms and 6 of 18 patients with negative angiograms required surgery for persistent major bleeding. Angiographic localisation of colonic bleeding allowed limited resection in 9 of 11 patients with control of haemorrhage in 8 (89%). Fourteen of 34 patients were managed non-operatively; of these 2 had minor recurrent bleeding. The overall mortality rate was 29%, the operative mortality rate 40% and the non-operative mortality rate 14%. A rational diagnostic approach is presented, emphasising the role of selective mesenteric angiography in the management and surgical strategy of major lower intestinal bleeding.

Non-invasive assessment of lower limb ischaemia by blood velocity wave-form analysis.

Clinical examination combined with angiography is conventionally used to assess lower limb arterial disease. The shape of the blood velocity wave form in the common femoral artery varies with the extent of proximal arterial disease, suggesting that wave-form analysis may provide additional haemodynamic information of potential value in surgical decision-making. This paper studies the use of two methods of wave-form analysis, pulsatility index and Laplace transform analysis, to assess lower limb arterial disease. The blood velocity wave form was measured non-invasively at the common femoral artery using a locally developed mean frequency processor and a commercial 9.5 MHz bidirectional Doppler ultrasound unit. Wave forms from 70 limbs (35 patients) with suspected atherosclerotic arterial disease and from 20 normal limbs with no history or signs of disease were studied. Both methods of wave-form analysis provided a statistically significant separation between patients with severe and moderate disease as assessed angiographically (P less than 0.001). These results suggest that significant aorto-iliac disease can be virtually excluded by a normal common femoral wave form. Furthermore, wave-form analysis may have an important role in the follow-up of patients after bypass grafting or iliac angioplasty and in the detection of presymptomatic aorto-iliac disease.

Primary sclerosing cholangitis: biliary drainage and duct dilatation.

A further extension of the U-tube technique is described in the treatment of six patients with primary sclerosing cholangitis who developed progressive jaundice and recurrent biliary sepsis. All six patients had operative intrahepatic duct dilatation and U-tube placement. Three patients in addition had a Roux-en-Y hepaticojejunal anastomosis. Five patients are improved and are well after a median follow-up period of 56 months. Two patients have had the U-tube removed electively. Three patients with progressive disease required further percutaneous catheter dilatation of intrahepatic strictures via the U-tube tract. Application of the technique permits evaluation of the biliary system by tube cholangiography and provides access in complex cases for repeated therapeutic intrahepatic stricture dilatation.

A system for rapid analysis of the femoral blood velocity waveform at the bedside.

The shape of the arterial blood velocity waveform varies with atherosclerotic disease and several methods of quantifying the shape in order to predict the severity of the disease have been described. These methods include pulsatility index, the Laplace transform method, and principal component analysis. This paper describes the development of a system which allows the operator to acquire, display, and store waveforms from each limb and then to quantify the waveforms at the bedside within a few minutes. The system includes a 10 MHz bi-directional Doppler unit, an instantaneous mean frequency processor, and an Apple II microcomputer fitted with an accelerator card. Both the Laplace transform parameters and the pulsatility index are computed and each result is printed in tabular form together with the averaged results of five waveforms from each limb. The printout is suitable for inclusion in the patient's folder. In initial clinical studies Laplace transform analysis exhibited a good correlation with aorto-iliac stenosis as assessed angiographically (R = 0.73 P less than 0.001 t test).

Prospective controlled trial of transhepatic biliary endoprosthesis versus bypass surgery for incurable carcinoma of head of pancreas.

53 patients with obstructive jaundice due to incurable carcinoma of the head of the pancreas were randomly allocated to percutaneous transhepatic placement of a permanent biliary endoprosthesis (PTE) or bypass surgery. After exclusions 25 patients in each group were treated. Technical success was achieved in 21 patients (84%) in the PTE group and 19 (76%) in the surgery group. The incidence of postprocedural complications (PTE 7, surgery 8) and 30-day mortality (PTE 2, surgery 5) were similar. Recurrent jaundice occurred more often in the PTE (8/21) than the surgery group (3/19). Duodenal obstruction developed in 3 patients in the PTE group. Although the initial median postprocedural hospital stay was significantly shorter in the PTE than the surgery group, the difference was no longer significant when readmissions for blocked endoprosthesis and gastric outlet obstruction were taken into account. There was no difference in the median survival time in the two groups (PTE 19 weeks, surgery 15 weeks).

Myelofibrosis, splenomegaly, and portal hypertension.

A patient with chronic myelofibrosis and massive splenomegaly developed portal hypertension with haematemesis occurring from radiologically proven oesophageal varices. Transjugular liver biopsy showed only myeloid metaplasia, and radiological evaluation of the portal vascular system was undertaken to establish a diagnosis of hyperkinetic portal hypertension as a basis for therapeutic splenectomy. The alternative and rare situation of splenic and portal vein occlusion was demonstrated and therefore removal of the spleen was not an appropriate procedure for relief of portal hypertension. The variceal bleeding was successfully controlled with injection sclerotherapy.

Two unusual causes of jaundice with similar ultrasound and CT findings.

The ultrasound and CT patterns of multilocular cystic areas in the liver in two jaundiced patients are presented. In one case the pattern represented a choledochal cyst and in the other an hydatid cyst of the liver. This unusual pattern, although nonspecific, should suggest one of these two diseases.

Fine-needle aspiration biopsy of malignant tumours of the abdomen.

Our initial experience of 50 patients who underwent fine-needle aspiration biopsy for suspected abdominal malignant disease confirms the safety and effectiveness of the technique. A positive diagnosis of malignant tumour was made in 36 out of 42 patients who were finally shown to have malignant disease. The correct diagnosis was made on 13 out of 17 patients with a pancreatic tumour; in 17 out of 17 with a liver tumour; in 3 out of 3 with renal masses; and in 3 out of 5 with other malignant lesions. Ultrasound was used for localization of the aspiration site in 38 patients, angiography in 11 patients and direct puncture in 2. During the biopsy of 55 sites, the needle was inserted into the abdomen 190 times and the only significant complication was the development of retroperitoneal haematoma in 2 patients.

Percutaneous transluminal dilatation of the renal artery: follow-up studies on renovascular hypertension.

Percutaneous transluminal dilatation of 80 renal artery stenoses was attempted in 68 patients. The procedure was technically successful in 58 (85%) patients. Fifty (86%) of the 58 patients were initially cured or improved. Life-table analysis of this group gives a cumulative success rate of 81% for a 3 year period. Hypertension recurred in only seven patients. There were no deaths related to the procedure, but four major complications occurred, including two secondary nephrectomies.

Interventional radiology - a new subspecialty.

Interventional radiology is a relatively new field concerned with the non-operative treatment of many conditions and diseases. Since its introduction the role of the radiologist has changed from that of a pure diagnostician to that of a physician actively engaged in patient diagnosis, management and treatment.

Percutaneous transluminal recanalization of complete iliac artery occlusions.

Percutaneous transluminal recanalization of ten complete iliac artery occlusions were attempted using the Grüntzig balloon catheter. The procedure was successful in eight of the ten occlusions, including all seven in which only one of the common or external iliac arteries was obstructed. Follow-up for periods of three to 13 months (average, eight months) showed continued patency in all cases. Although the long-term results remain to be determined, our preliminary results suggest that transluminal recanalization of complete obstruction of the iliac arteries is an alternative to surgery.

Transluminal dilatation in the treatment of peripheral arterial occlusive disease.

The authors review their experience over a 2-year period with transluminal arterial dilatation using the Grüntzig catheter. In 96 patients 136 aortoiliac or femoropopliteal arterial segments were dilated. The success rates at 1 year were 76% and 70%, respectively, for aortoiliac and femoropopliteal dilatations. The early and late results indicate that this procedure is useful in managing peripheral arterial occlusive disease in certain patients and that there are few complications when the procedure is carried out by a skilled angiographer.

Percutaneous transluminal dilatation and recanalization in the treatment of peripheral vascular disease.

Ninety-four successful transluminal angioplasties were followed up for as long as 15 months, during which time 15 failures occurred. Life-table analysis of this series gave a cumulative patency rate of 64%. The patency rate of 70% for iliac lesions, compared to 50% for the femoral-popliteal group, suggests that the former are likely to have a better long-term prognosis. In selected cases, transluminal angioplasty is a viable alternative to surgery that should be available to both patient and physician.