The role of percutaneous aspiration in the diagnosis of pancreatic abscess.

Percutaneous aspiration should be performed on pancreatic/peripancreatic fluid collections when an abscess is suspected. Thirty-one percutaneous aspirations were performed on 21 such patients and seven (33%) proved to have an abscess. A Gram stain after the aspiration is important, as it can make an immediate diagnosis of an abscess. By helping make an early diagnosis, percutaneous aspiration might reduce the high mortality rate associated with a pancreatic abscess while avoiding surgery in those who have sterile fluid collections. Two complications (6%) occurred: superinfection of a pseudocyst and a hemoperitoneum.

Abdominal aspiration biopsies. Sonographic v computed tomographic guidance.

One hundred eighty-four diagnostic aspirations performed on 169 patients were reviewed (1) to define the decision process regarding which guidance method (sonography v computed tomography) should be used on any given patient, and (2) to determine, once a guidance method was chosen, its accuracy and complication rate. Sonographic guidance (84%) proved to be an effective method for obtaining a correct diagnosis in 98% (110/112) of cystic masses and 79% (34/43) of solid masses. Computed tomography (16%) was used when sonography could not identify the mass or when the mass was small, deeply located, and often solid. Computed tomographic guidance provided a correct diagnosis in 100% (13/13) of cystic masses and 81% (13/16) of solid masses.

Diagnosis of pancreatic abscess via percutaneous aspiration.

UNLABELLED: The pre-operative diagnosis of a pancreatic abscess was not considered in a comprehensive review in 1972. However, advances in technology (Ultrasound--US, Computed Tomography--CT) has allowed guided percutaneous needle aspiration (PNA) of suspected pancreatic lesions. The purpose of this study was to evaluate the safety and diagnostic ability of PNA to differentiate acute pancreatic inflammatory masses from pancreatic abscess (PA). Thirteen patients underwent PNA after US or CT revealed an acute pancreatic inflammatory mass (12/13 cystic). One patient underwent a second aspiration. Clinical features T degrees--101.3 degrees F mean (13/13), leukocytosis 14,400 cu/mm (11/13). Aspirated material was gram-stained and examined for bacteria and leukocytes and cultured. RESULTS: PNA was accomplished successfully in all patients. Aspirate revealed bacteria in nine and pancreatic abscess was confirmed at surgery (8) or post-mortem exam (1). Four of five patients in whom no bacteria were visualized had medical resolution, the fifth had continued T degree and underwent a second aspiration which diagnosed a PA. PA contained moderate to large number of PML via aspiration. CONCLUSIONS: PNA provides a potentially important and safe diagnosis adjunct to earlier accurate differential diagnosis of pancreatic inflammatory masses from pancreatic abscess.

Acute pancreatitis: clinical vs. CT findings.

In a prospective study of 91 patients with acute pancreatitis, computed tomographic (CT) findings were correlated with the clinical type of acute pancreatitis. In acute edematous pancreatitis (63 patients; 16 with repeat CT), CT was normal (28%) or showed inflammation limited to the pancreas (61%). Phlegmonous changes were present in 11%, including one patient with focal pancreatic hemorrhage, indicating that clinically unsuspected hemorrhagic pancreatitis can occur. In acute necrotizing (hemorrhagic, suppurative) pancreatitis (nine patients; eight with repeat CT), no patient had a normal CT scan and 89% had phlegmonous changes. One patient had hemorrhagic pancreatitis and three had abscesses. In acute exacerbation of chronic pancreatitis (10 patients; three with repeat CT), there were pancreatic calcifications (70%), a focal mass (40%), and pancreatic ductal dilation (30%). On follow-up CT, the findings of acute pancreatitis did not always disappear with resolution of the clinical symptoms. This was especially true of phlegmonous pancreatitis, where the CT findings could persist for months.

The clinical significance of dilatation of the collecting system in the transplanted kidney.

The significance of dilatation of the collecting system of the transplanted kidney and its relationship to bladder distention was reviewed in 39 renal recipients examined by sonography (94 studies). The degree of pelvicaliceal (PCS), ureteral, and bladder distention was graded and correlated with the 24-h urine output, nuclear renal scan, and clinical follow-up. marked PCS distention can indicate obstruction (33%), especially when there is no associated bladder distention (60%) and a fluid collection lies along the path of the ureter. The 24-hr urine output did not influence the degree of PCS distention.

Diagnostic imaging of acute pancreatitis: prospective study using CT and sonography.

A prospective study using sonography and computed tomography (CT) was performed on 102 patients consecutively identified as having acute pancreatitis to see which method provided the most information. Each examination was graded for visualization of the pancreas, extent of disease, and the detection of complications. CT was found to be of significantly greater value than sonography due to the high percentage (38%) of nondiagnostic studies with the latter method. Of the 102 patients, 70% had abnormal CT studies, including 18% with extrapancreatic phlegmons, 10% with pseudocysts, 5% with acute hemorrhage, and 3% with pancreatic abscesses.

Therapeutic percutaneous aspiration of pancreatic pseudocysts.

The therapeutic efficacy and safety of percutaneous aspiration of chronic pancreatic pseudocysts was evaluated. Eight patients underwent aspiration a total of ten times. Permanent resolution was obtained in two patients and a third nonsurgical candidate was offered an alternative therapeutic modality. This procedure is simple, rapid, and safe and could become the initial approach to selected patients with a chronic pancreatic pseudocyst.

The clinical significance of acute pancreatic hemorrhage.

Computed tomography (CT) has the ability to demonstrate acute hemorrhage both within the pancreatic parenchyma and the adjacent retroperitoneal spaces. It was found that during the acute phase of pancreatic hemorrhage (about 1-7 days) the CT number of hemorrhage is significantly greater than that of the gland. At the present time the true incidence of pancreatic hemorrhage and the relation of the CT demonstration of hemorrhage to the clinical entity of hemorrhagic pancreatitis is unclear. The CT, laboratory, and clinical findings in eight patients with acute pancreatitis were analyzed to help answer these questions. This limited experience suggests pancreatic hemorrhage is more frequent than hemorrhagic pancreatitis as currently defined clinically.

The sonographically solid appearing benign cystic teratoma.

The sonographic appearance of 6 solid benign cystic teratomas (in 5 patients) was reviewed. Three of these tumors were difficult to identify due to the presence of acoustical shadowing obscuring the posterior portions of the tumors. This appearance was mistaken ultrasonically for bowel gas. The tumors were diagnosed by abdominal radiographs showing calcifications, teeth and/or radiolucency due to fat. With the presence of a clinically palpable pelvic mass in a young woman, and an apparently normal sonogram, an abdominal radiograph should be considered to look for evidence of a benign cystic teratoma.

Diagnostic imaging of hepatic abscesses: a retrospective analysis.

Seventeen patients with pathologically proven intrahepatic abscesses seen over a 12 month period were retrospectively evaluated. Of these 17 patients, 16 had at least three of the four commonly used imaging techniques for the evaluation of hepatic abscesses, including scintigraphy with technetium-99m-labeled sulfur colloid and gallium-67 citrate, sonography, and computed tomography. Of the 17 abscesses, 12 were of pyogenic and five were of amebic origin. Technetium-99m sulfur colloid correctly identified 14 of 16 abscesses; gallium, nine of 10; sonography, 12 of 16; and computed tomography, 15 of 17. The rational approach to the diagnosis of intrahepatic abscesses should be a 99mTc sulfur colloid scan followed, if necessary, by either sonography or CT. In equivocal cases a gallium scan may be of value.

Para-aortic lymphocyst.

Although numerous articles regarding the etiology, incidence, complications, and management of pelvic lymphocysts have been published in the American literature since 1958, there has been no mention of para-aortic lymphocyst as a complication of para-aortic node dissection. Two recent cases of symptomatic para-aortic lymphocyst have prompted a review of our para-aortic node dissection technique when this procedure is not combined with a more extensive pelvic lymphadenectomy. Our modification in technique is to use retroperitoneal para-aortic drainage by constant pressure-controlled suction following closure of the posterior parietal peritoneum, and the results in our first 15 patients are presented. There were no complications related to the drainage technique. Abdominal ultrasound and intravenous urography have proved to be excellent diagnostic tools in the initial evaluation and subsequent follow-up of para-aortic lymphocytes.

Sonic silhouetting of the aorta.

The diagnosis of diseases involving and arising from structures around the abdominal aorta has been described. Sonic silhouetting of the wall of the aortic due to lymphomatous involvement of the para-aortic lymph nodes is well known. It may be found with metastatic para-aortic lymphadenopathy, retroperitoneal fibrosis and pancreatic carcinoma where the tumor is adjacent to the aortic wall. Sonic silhouetting of the aorta associated with a pancreatic mass indicates malignancy. Extensive sonic silhouetting due to pancreatic carcinoma can have the appearance of a clot containing abdominal aortic aneurysm.

CT of acute pancreatitis: interim assessment.

a retrospective review of 102 ptients with the clinical diagnosis of acute pancreatitis undergoing computed tomographic (CT) evaluation during a 9 month period revealed 32 patients with abnormal CT scans. All 32 had enlargement of the pancreas. The extent of inflammatory process on these patients was examined. Twenty patients exhibited a phlegmonous mass extending into the region of the lesser sac. There was involvement of the left anterior pararenal space in 13 (the right in three and both in four). Eight patients demonstrated involvement of the posterior pararenal space, and in seven of these the inflammatory process extended down the psoas muscle into the pelvis. Five patients had involvement of the transverse mesocolon and small bowel mesentery. Eight patients developed a pseudocyst during the acute phase of the disease, 11 developed a pancreatic abscess, and two showed evidence of pancretic hemorrhage. This experience prompted a prospective study of the clinical course of acute pancreatitis relative to the extent of disease as recognized by CT.

Sonographic patterns of ectopic pregnancy - how do they help in making the diagnosis?

The diagnosis of ectopic pregnancy is clinically difficult. To determine how the different sonographic patterns help in making the diagnosis of ectopic pregnancy, the ultrasound examinations of twenty-three patients were retrospectively reviewed. Four sonographic types of ectopic pregnancy were found: Type 1--Cystic adnexal mass with a fetal pole. Type 2--Cystic adnexal mass with no fetal pole. Type 3--Complex or solid adnexal mass. Type 4--Pelvis fluid with no mass. In Type 1, a specific ultrasound diagnosis of ectopic pregnancy could be made. In Types 2, 3 and 4 the sonographic findings although suggestive of an ectopic pregnancy were not specific. In these cases the diagnostic accuracy was increased if culdocentesis was performed when ultrasound demonstrated fluid in the pelvis. Unlike previous reports, uterine size, endometrial echoes and myometrial echoes were found to be of no value in making the diagnosis. The positive pregnancy test increased the diagnostic specificity of the ultrasound examination. Even if the pelvic sonogram was normal, an ectopic pregnancy could not be excluded if the pregnancy test was positive.

Sonography of the renal arteries: left lateral decubitus position.

Despite the routine visualization of many of the major branches of the abdominal aorta using current state of the art sonography equipment, the renal arteries are still infrequently seen in normal patients and are rarely seen in patients with abdominal aortic aneurysms. Longitudinal scanning in the left lateral decubitus position will frequently visualize the origin of the renal arteries from the aorta and/or the right renal artery as it crosses under the inferior vena cava. Using this technique the renal arteries in 16 of 20 patients were visualized. The experience with this technique so far is limited to three patients with aortic aneurysm. In two, the relation of the aneurysm to the renal arteries could be delineated.

Necrotic carcinoma of the pancreas: "the pseudo-pseudocyst".

Necrotic adenocarcinoma of the pancreas may simulate a cystic mass of the pancreas on computed tomography and ultrasound. A clinical history suggesting malignancy should alert the radiologist to this infrequent occurrence.