Significance of thickening of the upper gastrointestinal tract on cross sectional imaging: Endoscopic correlation.

AIM: To report the endoscopic findings for a cohort of patients referred for discussion at a specialist oesophago-gastric multi-disciplinary team (MDT) meeting, on the basis of CT mural thickening. PATIENTS AND METHODS: The records of patients discussed at a regional oesophago-gastric MDT during the time 1st April 2014 to 5th February 2016 were reviewed in order to identify patients who were endoscopy naïve at the time of CT and scans re-reviewed to measure maximum wall thickness. RESULTS: 456 patients were referred for discussion, 126 met the inclusion criteria. Endoscopy confirmed malignancy in 50/126 patients (40%); by site, oesophagus (21/67, 31%), stomach (25/50, 50%), duodenum (4/9, 44%). Malignancy was confirmed for 10/48 (21%) patients with isolated wall thickening, for 11/33 (33%) when regional lymphadenopathy was identified, and for 28/44 (64%) when possible metastatic disease was identified. The commonest source of diagnostic uncertainty was thickening around the gastro-oesophageal junction in the presence of a hiatal hernia. Wall thickening >20 mm was strongly associated with malignancy compared to thickening =<20 mm (p < 0.0001). Using this threshold would have resulted in a sensitivity of 32/50 (64%), a specificity of 55/76 (72%), a positive predictive value of 32/53 (60%) and a negative predictive value of 55/73 (75%) in this cohort. CONCLUSIONS: The cancer pick-up rate of 40% and the medicolegal consequences of a missed cancer suggest that endoscopy should be performed in all patients with CT identified mural thickening. In the presence of isolated mural thickening and a normal endoscopy, no formal MDT discussion is required.

A comparison of infections and complications in central venous catheters in adults with solid tumours.

AIM: The aim of this study is to compare the complication rates of three vascular access devices in patients with solid tumours having infusion chemotherapy. MATERIALS AND METHODS: An observational study of 58 central venous catheter (CVC) lines inserted in 55 patients with solid tumours requiring infusional chemotherapy was performed. The study was conducted between January 2011 and August 2013, looking at complication and infection rates as primary outcomes. Data were recorded from patients with 19 tunnelled cuffed silicone catheters, nine with peripherally inserted central catheters (PICCs) and 30 central venous ports. RESULTS: The two CVC groups (ports and non-ports) matched equally in terms of tumour site; all patients with solid tumours were included, haematology patients were excluded and chemotherapy regimens were comparable. Thirteen out of 28 non- ports had complications compared with one out of 30 central venous ports. Ten out of 19 tunnelled catheters had complications including three displacements and seven were removed due to infection. There were no reports of line-related sepsis in the PICC or ports. Three out of nine PICC lines had complications including two displacements and one PICC blocked permanently requiring removal. In addition, one port out of 30 was removed due to erosion through the skin. There were no episodes of thrombosis or fibrin sheath formation related to any of the devices. CONCLUSIONS: In our study, we demonstrated that central venous ports and PICC lines in patients undergoing infusional chemotherapy had lower line infection rates than tunnelled catheters, and only ports have been shown to be almost complication-free. In addition, we found infection rates higher in CVCs s cared for by patient/carers rather than hospital only care, and higher in colorectal patients with stomas. Therefore, we recommend that central venous ports are a safe, acceptable CVC option for infusional chemotherapy for adults with solid tumours.

Active retropharyngeal hemorrhage from an acute thyrocervical artery injury: a rare complication of hyperextension cervical spine injury.

BACKGROUND: Acute vascular injury is uncommon after cervical spine injury. We describe a recent case of active retropharyngeal bleeding from the thyrocervical artery after an acute cervical spine injury. OBJECTIVES: The case illustrates an unusual vascular injury diagnosed by 64-slice multidetector computed tomography (MDCT) and managed successfully by emergency transcatheter embolization. CASE REPORT: A 65-year-old woman presented to the Emergency Department after a fall. MDCT scans of the cervical spine revealed a fracture of C5 and a large prevertebral hematoma. Subsequent MDCT carotid angiography revealed active bleeding from a branch of the right thyrocervical trunk. Superselective catheterization into the right thyrocervical trunk confirmed this as the source vessel. A 3-mm coil was deployed without complication. CONCLUSION: This case illustrates an unusual arterial injury in the context of cervical spine trauma and how, as endovascular services become more accessible out of hours, the management of patients with acute arterial injury is increasingly a multidisciplinary team effort. Early recognition by the emergency physician of potential vascular injury and prompt referral for appropriate imaging will expedite treatment and improve clinical outcome.

Spontaneous intracranial hypotension: a cause of severe acute headache.

Severe acute headache is a common presenting symptom to an accident and emergency department. Spontaneous intracranial hypotension (SIH) is an increasingly recognised cause of these symptoms and has characteristic clinical and imaging findings. SIH is characterised by headache worse on standing, low opening cerebrospinal fluid pressures at lumbar puncture and uniform pachymeningeal enhancement with gadolinium enhanced magnetic resonance imaging of the brain, all in the absence of dural trauma. Atypical presentations occur and severe neurological decline can rarely be associated with this condition. A review of five patients presenting recently to our institution with classical imaging findings together with a review of the literature is presented.

Spontaneous intracranial hypotension: a cause of severe acute headache.

Severe acute headache is a common presenting symptom to an accident and emergency department. Spontaneous intracranial hypotension (SIH) is an increasingly recognised cause of these symptoms and has characteristic clinical and imaging findings. SIH is characterised by headache worse on standing, low opening cerebrospinal fluid pressures at lumbar puncture and uniform pachymeningeal enhancement with gadolinium enhanced magnetic resonance imaging of the brain, all in the absence of dural trauma. Atypical presentations occur and severe neurological decline can rarely be associated with this condition. A review of five patients presenting recently to our institution with classical imaging findings together with a review of the literature is presented.