Combined assessment (aspiration cytology and mammography) of clinically suspicious breast masses.

We examined the safety and utility of the combined assessment of aspiration cytology and mammography in 705 women who had clinically suspicious or malignant palpable breast masses. Histological assessment confirmed 176 benign and 529 malignant lesions. There were no incorrect (false positive) diagnoses made in the 176 benign masses when combined assessment was used (specificity 1.0; predictive value 0.86); in isolation, however, there was a false positive cytological diagnosis ('papillary carcinoma') and 3 false positive mammographic diagnoses. Benign disease (false negative) was incorrectly diagnosed by combined assessment in 4 of the 529 malignant masses (sensitivity 0.99; predictive value 0.98): cytological diagnoses were of fat necrosis (2) and benign cells on cytospin (1) and aspiration biopsy (1); mammographic diagnoses were of benign disease (2) and normality (2). Indeterminate ('atypical', 'suspicious') diagnoses were problematic and frequent (overall 223 (31.6%), malignant masses 137 (25.9%), benign masses 86 (48.9%); cytology 117 (16.6%), mammography 141 (20%). Thus, with the combined assessment of mammography and cytology in clinically suspicious breast masses, a decisive diagnosis was made in about two-thirds of cases allowing the safe commencement of therapy; the balance of patients required core or excision biopsy.

Duodenal intramural pseudodiverticulosis.

Although esophageal intramural pseudodiverticulosis is well described, similar pathology has not been demonstrated elsewhere in the gastrointestinal tract. Three cases are reported with identical changes in the duodenum, one of which had simultaneous esophageal involvement. All three patients were alcohol abusers.

Subpulmonary haemothorax: 387 cases.

The diagnostic features of subpulmonary haemothorax (SH) are often overlooked. A retrospective review of 399 consecutive patients discharged with diagnoses of post-traumatic haemo- or haemopneumothorax yielded 51 (12.8 per cent) instances of SH on the initial radiographs. In 24 (47.1 per cent) of these initial diagnosis of SH had been missed. A concerted teach-in followed in order to reduce the rate of error. In a subsequent prospective study of 1773 consecutive patients with haemothorax (510) or haemopneumothorax (1263), mostly due to penetrating injuries, and who had undergone pre-interventional erect chest radiography, 336 (19.0 per cent) had the blood confined to the subpulmonary position; 156 (12.4 per cent) of the haemopneumothoraces and 180 (35.3 per cent) of the pure haemothoraces presented in this way. Confirmatory lateral decubitus radiography was necessary in 141 (42.0 per cent) of the SHs but initial diagnostic errors were confined to six cases (1.8 per cent). Comparison of the 336 SH patients and the 1437 presenting with more florid radiological signs showed only one significant difference in management and outcome: emergency thoracotomy rates of, respectively, 0.9 per cent and 9.2 per cent (P less than 0.0005). We conclude that SH is a common and normal presentation of less than massive haemothorax and we stress the diagnostic radiological features.

Cystic duct entry--another cause of pseudocalculus.

Certain pitfalls face the endoscopist during ERC in the diagnosis of common bile duct stones. False-positive filling defects for calculi may be caused by air bubbles, blood clot, tumor, and the pseudocalculus sign of the lower common bile duct (CBD) due to sphincter spasm. Another false positive may be encountered by the presence of a filling defect at the confluence of the cystic duct and common bile duct, and we report on three such cases. The cause of this pseudocalculus sign of the mid-CBD is not clear. We speculate that it may arise as a result of an unopacified jet of bile flowing from the cystic duct displacing contrast in the CBD.

The spectrum and natural history of common bile duct stenosis in chronic alcohol-induced pancreatitis.

Sixty patients with chronic alcohol-induced pancreatitis with endoscopic retrograde cholangiopancreatography evidence of common bile duct stenosis were studied to determine the clinical spectrum and natural history of this complication, as well as the indications for biliary bypass. In 17% of patients, common bile duct stenosis (CBDS) was an incidental finding at ERCP, while in the remaining cases pain and jaundice were the predominant symptoms in 35% and 48%, respectively. Biliary drainage was performed in 38% of patients for persistent or recurrent jaundice, cholangitis, and while undergoing pancreatic duct or cyst drainage procedures for pain. The benign nature of CBDS in chronic alcohol-induced pancreatitis (CAIP) in patients without persistent jaundice is emphasized. In particular, no histologically proved cases of secondary biliary cirrhosis were noted. The majority of patients with CBDS due to CAIP may be safely managed without biliary bypass but require close follow-up.

Acute colonic pseudo-obstruction. Current diagnosis and management.

Twenty-nine patients with acute colonic pseudo-obstruction were treated over a 6-year period. All had gross abdominal distension which followed either serious systemic illness (23 cases), major surgery (4) or trauma (2). The predominant radiological features were disproportionate segmental or localised dilatation of the caecum and proximal colon, with a relative paucity of distal colonic gas. The correct diagnosis was established and mechanical obstruction excluded in the majority of cases (24) by contrast enema examination. In the remaining 5 cases the diagnosis was made on colonoscopy (4) or at laparotomy (1). Successful colonoscopic decompression was achieved in 2 of 4 cases. Eight patients underwent laparotomy and 3 of 4 patients with caecal perforation and peritonitis died. Two of 21 patients treated conservatively died. Persistence of colonic distension beyond 72 hours, caecal diameter greater than 12 cm or overlying abdominal tenderness indicates urgent decompression. Caecostomy is the advised procedure in patients with non-perforated caecal distension. Prompt recognition and treatment of the condition should eliminate delay in decompression and minimise the risk of caecal perforation.

The role of colonoscopy in the diagnosis of tuberculosis.

The value of colonoscopy in the diagnosis of ileocolonic tuberculosis at Groote Schuur Hospital was assessed and the published world experience reviewed. During a 4-year period, abdominal tuberculosis was diagnosed in 94 patients, of whom 18 manifested involvement of the ileocecal area and/or colon. Colonoscopy, performed in 10 of these, provided diagnostic information in 7. Since the endoscopic appearance of diseased mucosa is nonspecific, adequate bacteriological and histological assessment of biopsied tissue is essential to differentiate tuberculosis from other disorders that may simulate it. We stress the importance of microscopy and culture for Mycobacterium tuberculosis.

Yersinia enterocolitica and Crohn's disease. A case report.

A case of simultaneous infection with Yersinia enterocolitica and Crohn's disease is described. Only 1 similar case has been reported. The similarities between the two conditions and the differentiating features are described.

Disproportionate steatorrhoea in alcohol-induced calcific pancreatitis.

The pancreatograms, as assessed by endoscopic retrograde cholangiopancreatography, of 51 patients with alcohol-induced calcific pancreatitis (AICP), were compared after division of the patients into three groups according to their insufficiency patterns. The first group, consisting of 18 patients, was labelled as having 'disproportionate steatorrhoea' characterized either by overt steatorrhoea and mild or no diabetes or by mild steatorrhoea and a normal glucose tolerance test result. The second group of 15 patients had severe diabetes associated with overt, mild or no steatorrhoea and constituted the 'insufficiency' group. The third group consisted of 18 patients with little or no pancreatic insufficiency. Twelve of the 18 patients with disproportionate steatorrhoea had a proximal complete or incomplete obstruction of their main pancreatic ducts, compared with 3 out of 15 in the insufficiency group and 4 out of 18 in the group with little or no pancreatic insufficiency. In this study an increased incidence of complete or incomplete obstruction (P less than 0,002) was found in the patients with disproportionate steatorrhoea compared with the other two groups. This suggests that obstruction to pancreatic flow may account for the dominant clinical presentation of steatorrhoea in some patients with AICP.

Comparison of the oral (PABA) pancreatic function test, the secretin-pancreozymin test and endoscopic retrograde pancreatography in chronic alcohol induced pancreatitis.

The oral (PABA) pancreatic function test (PFT), the secretin-pancreozymin test and endoscopic retrograde pancreatography (ERCP) have been carried out in 32 patients with suspected chronic alcohol induced pancreatitis (CAIP) in order to evaluate which, if any, test was most likely to confirm the provisional diagnosis. Thirty one patients had changes of minimal (n = 6) moderate (n = 7) or advanced (n = 18) chronic pancreatitis on pancreatography, whilst one patient had a pancreas divisum. Eight hour urinary PABA excretion was significantly reduced in patients with moderate and advanced structural changes (p less than 0.001) and correlated significantly with all parameters of the PFT, although eight patients with an abnormal pancreatogram and pancreatic function test had a normal PABA value. The PFT was abnormal in 23 patients, but normal in five patients with an abnormal pancreatogram and low PABA value. Most patients with minimal change pancreatitis had a normal PABA test and PFT. We conclude that pancreatography appears to be the most sensitive method for detecting chronic pancreatic damage and for confirming a clinical diagnosis of chronic alcohol induced pancreatitis. Both the PFT and PABA test are useful confirmatory tests and whilst the PFT is slightly more sensitive for assessing pancreatic exocrine function, the PABA test is well tolerated and simple to perform. It may therefore be the complementary investigation of choice for this group of patients.

The threatened caecum in acute large-bowel obstruction.

The recognition of intramural caecal gas as a sign of necrosis and incipient caecal rupture in cases of acute large-bowel obstruction is emphasised. Gas was noted within the caecal wall in two cases of large-bowel obstruction due to recto-sigmoid carcinoma. At operation the proximal large bowel was found to be non-viable in one of these, and the other required a repeat operation for gangrenous bowel two days after the initial procedure. These cases illustrate the importance of specifically looking for intramural caecal gas in patients with acute large-bowel obstruction, and its value in identifying the threatened caecum, especially if marked distension is present.

Crohn's disease of the oesophagus. A case report.

Crohn's disease is described as a disease which may involve the entire gastro-intestinal tract from the mouth to the anus. Involvement of the oesophagus is well recognized but relatively rare. We wish to describe the unusual clinical presentation of intense dysphagia in a patient who was proved to have occult ileocolonic Crohn's disease.

Structure and function in noncalcific pancreatitis.

A group of 47 carefully assessed patients with noncalcific pancreatitis was studied with ERCP and the secretin pancreozymin pancreatic function test (PFT). A simple scoring system was constructed for each of the PFT indices to create a PFT score for each patient and four grades of ERCP abnormality were documented, from minimal to gross. A simple pancreatic pain score was constructed to allow for the inclusion of patients with classical pancreatic pain in the absence of acute attacks associated with an elevated serum amylase. In general there was a correlation between the degree of structural change and functional impairment, with patients with the worst pancreatic function having the grossest ERCP changes. ERCP was abnormal in 45 of the 47 patients (96%) and the PFT in 34 of the 47 (72%). However, there were some marked discrepancies between the two methods, in particular two patients with normal function in the presence of gross structural changes. ERCP proved to be the more sensitive diagnostic technique than the PFT in this group of patients.

Early detection of colorectal cancer using faecal occult blood tests.

Five thousand and twelve asymptomatic patients over the age of 40 years who were on a normal diet were asked by their general practitioners to perform a Hemoccult (Röhn Pharma (Noristan] faecal occult blood test over 3 days. Of the 3 422 patients (68%) who completed the test, 99 (3%) had a positive result. The patients with a positive result then again performed the Hemoccult test, this time over 6 days on a restricted diet. Thirty-two of these patients had a positive result on the second test. Only the 32 patients who had a positive result for the second test were fully investigated (including double-contrast barium enema and colonoscopy); 27 patients (84%) were found to have neoplastic disease. Twelve had invasive carcinoma (9 Dukes' A, 2 Dukes' B and 1 Dukes' C), 6 of these also having 10 adenomas, while the other 15 had 27 adenomas which were identified and removed at colonoscopy. Barium enema missed 3 carcinomas (all Dukes' A) and identified only 16 (43%) of the 37 adenomas. Those patients found to have a negative result for the second Hemoccult test are being followed up.

The mucosal pattern of the gall bladder ("areae cholecysticae").

During endoscopic retrograde cholangiopancreatography (ERCP) the mucosal fold pattern of the gall bladder can be seen if radiographs are made before the contrast medium has mixed with the bile. These appearances are demonstrated by studies both in vivo and in vitro.

Abdominal tuberculosis. A 10-year review.

Clinical experience with 125 patients with abdominal tuberculosis (46 of whom had intestinal tuberculosis, 8 mesenteric tuberculous lymphadenitis and 71 the peritoneal form) is presented. The diagnosis, especially in the intestinal cases, was seldom considered and a wide variety of conditions was simulated. Ileocaecal tuberculosis accounted for only 11 (24%) of the intestinal cases, while 17 patients (37%) had more distal involvement. A number of patients with diffuse colonic tuberculosis were seen. Chest radiographs showed that 51% of the 125 patients had active tuberculosis, but were completely normal in 38% of cases. Tuberculin skin testing was negative in 45% of cases. The pathogenesis, pathological features, diagnostic difficulties and complications are discussed, and the importance of considering the diagnosis is stressed.

Computed tomography of fatty infiltration of the liver.

Fatty infiltration of the liver can be identified by means of and may have a spectacular appearance on computed tomography (CT). Fifteen cases are described and the clinical associations are discussed. CT may be useful as a primary technique for the diagnosis of a fatty liver when performance of a biopsy is contraindicated.

Inflammatory bowel disease in Cape Town, 1975-1980. Part I. Ulcerative colitis.

Previously documented and new patients with ulcerative colitis seen between 1975 and 1980 in the Gastro-intestinal Clinic of Groote Schuur Hospital were studied to establish the local incidence and clinical features of this disease. There were 220 patients and the mean follow-up was 7,7 +/- 0,4 years. Sixty per cent of patients were White, 37% Coloured and 3% Black. The incidence for the Coloured and White population was calculated to be 1,3 and 2,4/100 000 per year during 1970-1974 and 1,6 and 2,1/100 000 per year during 1975-1980, respectively. In Jews the rates were 8,5 and 10,4/100 000 per year for the two periods. Insufficient data are available to calculate an incidence for the Black population. The disease was limited to less than 15 cm above the anus in 14% of patients, to the rectosigmoid colon in 45%, and to the rest of the colon in 40%. Although the severity of symptoms was related to the extent of disease, 22% of patients with extensive colitis had mild symptoms, while 15% with disease limited to the rectum had severe symptoms. The clinical features were similar in the White and Coloured population groups. A total colectomy was performed on 20% of patients with extensive colitis; in 2% the disease was complicated by colonic carcinoma.