Breast inflammation in type 1 diabetes.

BACKGROUND: Lymphocytic mastitis is an uncommon fibroinflammatory disease of the breast which occurs in patients with longstanding diabetes. Various imaging patterns in mammography, ultrasound and magnetic resonance imaging (MRI) have been widely described. This communication wishes to provide some explanation to the variation of imaging findings by a study of follow-up cases and present young nonlactating women who had abscess as the first clinical manifestation of type 1 diabetes. METHODS: Five women with pathologically confirmed lymphocytic mastopathy and 8 women with type 1 diabetes who presented with breast abscess at National Guard Hospital, Riyadh were studied. The ultrasound, mammographic and MRI features were analyzed. Follow-up of 2 to 4 years was done. The clinical findings were analyzed in a descriptive way. RESULTS: A total of 13 women were studied. Age ranged from 22-54 years. The clinical presentation was a painless hard breast mass in the 5 cases with lymphocytic mastitis and painful mass in 8 women with breast abscess, 3 of which were non-lactating young women. The common imaging finding at mammography was diffuse or focal stromal distortion unilaterally or bilaterally in 4 cases (80%). Complete clinical and mammographic resolution occurred in 2 (40%) of the cases while it was only partial in the rest with lymphocytic mastopathy. Initial ultrasound showed stromal changes in 3 (60%), mass-like lesion in 1 (20%) and normal in 1 (20%). At follow-up ultrasound examination, all had interval development of dense acoustic shadowing representing the previous lesions between 1-2 years. CONCLUSION: Lymphocytic mastitis can have various patterns at the initial presentation at ultrasound. However, the chronic change at follow-up in this study was intense acoustic shadowing without any mass in all. Type 1 diabetes is suggested in young non-lactating females presenting with breast abscess.

Is it Crohn's disease or intestinal tuberculosis? CT analysis.

A computed tomographic (CT) analysis of 36 patients with differential diagnosis of intestinal tuberculosis (IT) or Crohn's disease (CD) in barium gastrointestinal studies was undertaken to identify distinguishing bowel wall or mesenteric features which could provide a radiological definitive diagnosis. Final diagnoses obtained in 32 cases were tuberculosis (N = 18), CD (N = 9), carcinoid (N = 2), chronic appendicitis (N = 2) and bowel infarction (N = 1). In IT, the bowel wall changes were varied: absence of wall thickening (N = 6), minimal asymmetric wall thickening with and without mucosal tethering (N = 8), minimal symmetric wall thickening often with mild peritonitis (N = 3), exophytic mass encircling bowel lumen (N = 4). Mural stratification (target sign) was not found. CD showed concentric or symmetrical wall thickening ranging from 0.6 to 1.5 mm and mural stratification occurred in about a half of the cases. Lymphadenopathy was the commonest associated feature in both but in IT, the nodes were larger and a third had necrotic centers. Displacement of bowel loops was more often due to enlarged lymphadenopathy in IT while in CD it was frequently due to fibrofatty change. CT was able to provide the correct diagnosis in 26 out of these 32 (81%) cases of indeterminate barium studies. CT is recommended when barium gastrointestinal studies are unable to differentiate between intestinal tuberculosis and Crohn's disease.

The value of ultrasonography in the x-ray negative non-traumatic acute abdomen.

Over a period of three years, 122 patients who presented with acute abdomen, and had normal abdominal x-rays on admission were examined with Ultrasonography (U/S) in order to evaluate the use of Abdominal Ultrasonography in patients with negative x-ray findings. Sonographic evaluation was undertaken with Siemen's equipment (Sonoline S1-2) with a 3.5 MHz sector transducer for the abdominal organs and 5 or 7.5 MHz sector transducer for the abdominal organs and 5 or 7.5 MHz linear array for the intestines and right iliac fossa. Analysis included features or organ inflammation, bowel wall changes, and motility and collections. Ultrasound guided aspiration and drainage were done when necessary. Surgical confirmation was obtained in 86 out of the 122 cases. The commonest finding were appendicitis, intestinal obstruction and gynaecological pathologies. Ultrasound correctly identified 76 out of the 86 positive cases (88%). The sensitivity, specificity, positive predictive valve and negative predictive valves were 88%, 78%, 96% and 83% respectively. There were seven (7) false negative findings, and three (3) false positive cases. Pancreatitis was the commonest cause of false negative findings. The study clearly shows that ultrasound imaging can identify the underlying pathology in 88% of patients with acute abdomen with negative, plain abdominal x-ray findings. Ultrasound guided interventional procedures can also be done without delay.

Radiological evaluation of complications of intestinal tuberculosis.

Complications of intestinal tuberculosis may be masked. This study aims to heighten awareness of these unusual clinical complications and the radiological findings in such cases. Over a period of 5 years, 21 patients with proven intestinal tuberculosis, 13 of whom presented with complications, are presented in this report. Radiological diagnosis was by barium gastrointestinal studies and computed tomographic (CT) evaluation. Surgical specimens and histopathology confirmed the diagnosis. The commonest complication was intestinal obstruction (N = 6). Others were esophagobronchial and duodenocolic fistulas (N = 2), significant gastrointestinal hemorrhage (N = 3) caused by ulcers in the small bowel and colon, and malabsorption syndrome (N = 3) caused by diffuse small bowel infiltration in 2 cases and duodenocolic fistula in the third case. None of the patients presented were immunocompromised. Though uncommon, tuberculosis should be considered in patients presenting clinically with intestinal obstruction, significant gastrointestinal hemorrhage and malabsorption state.

Computed tomography compared with small bowel enema in clinically equivocal intestinal obstruction.

OBJECTIVE: To compare the findings in computed tomography (CT) and small bowel enema (SBE) in clinically equivocal small bowel obstruction in order to identify the reasons for the limitation of CT evaluation. SUBJECT AND METHOD: Over a period of 5 years, 49 patients who had both CT and SBE within a period of 1 week were analysed. The findings at SBE were categorized into partial low-grade, partial high-grade and complete obstruction and compared with the CT findings. A critical analysis of the CT false-negative cases was made. The predictive values for the determination of the presence of obstruction in CT were also obtained. RESULTS: Forty-three out of the 49 patients had proven intestinal obstruction. CT correctly identified 34 cases including 19 of 20 with partial high-grade obstruction, two with complete obstruction and 13 out of 21 cases of partial low-grade obstruction. Among those cases with low-grade obstruction cases with complex or long segment narrowing or with masses were correctly identified while six patients with short stenotic segment due to various causes were not. CT also had two false-positive findings of obstruction in patients with mesenteric infarction. SBE had neither false positive nor false negative. The sensitivity, specificity, positive predictive value and negative predictive values for CT were 83%, 67%, 94% and 36%, respectively. Abrupt transition from dilated to collapsed loops in CT were caused by various intraluminal lesions apart from adhesions. CT was superior to SBE in showing extraluminal masses, revealing abscesses, tuberculous lesions and malignancy anterior adhesions as well as features of strangulation. CONCLUSION: Apart from degree of obstruction and the presence of masses, the length of the stenotic part also affected CT detection. Abrupt change from dilated to collapsed segment could be due to various transmural and intraluminal lesions although adhesions was the commonest lesion. While SBE is more accurate in identifying the presence and location of obstruction, CT is superior for detection of the cause of small bowel obstruction and also for the presence of strangulation. In places where CT is more widely used for intestinal obstruction, SBE evaluation could be prudently considered in CT negative cases of clinically equivocal intestinal obstruction.

A clinico-radiological correlation of breast diseases during lactation and the significance of unilateral failure of lactation.

Over a period of three and a half years, 58 patients who for various reasons had both ultrasonography and mammography during lactation were analyzed to identify and correlate breast diseases, if any, with the clinical symptomatology. The clinical symptoms were breast pain, mass and/or unilateral failure of lactation. Twenty-one (21) out of 58 (36%) had abnormal findings. The commonest was galactocele (N = 9) which usually presented with breast pain and a mass. Unilateral failure of lactation and in particular refusal of the infant to suckle (infant rejection sign) was associated with breast lesions such as malignancy (N = 4), breast abscess (N = 2) and infected galactocele (N = 2). Mammographically, the affected breast showed a significantly reduced ductal pattern as well as significant pathology such as a mass. Symptomatic patient with bilateral successful lactation had benign breast lesions such as simple galactocele and fibroadenoma. Unilateral failure of lactation in a symptomatic breast may signal serious breast pathology during lactation and a thorough radiological evaluation including core biopsy of solid lesions and mammography is therefore suggested. Patients with breast pain and or mass but with bilateral normal lactation tend to have benign breast changes and ultrasound alone was adequate in evaluating these patients.

Diagnosis, management and prognosis of obstructive jaundice in Ile-Ife, Nigeria.

A 5-year review of 50 patients, 28 males, 22 females, with a mean age of 42 years, operated for obstructive jaundice at Ile-Ife, Nigeria was undertaken. Neoplasms of the pancreas, liver, and bile duct were the common causes. Percutaneous Transhepatic Cholangiography (PTC) with hypotonic duodenography was excellent in determining the underlying lesions. Pancreatic carcinoma accounted for 28% of cases, cholelithiasis 24%, hepatoma 22%, metastatic cancer 14%, bile duct carcinoma 10%, and traumatic pancreatic pseudocyst 2%. The patients with malignancies were older than those with biliary calculi. Biochemically, elevated alkaline phosphatase, and conjugated hyperbilirubinaemia, particularly in malignant obstructions, were diagnostic. Benigh bile ductal obstructions were surgically managed without any mortality. Malignant obstructions were surgically managed without any mortality. Malignant obstructions with their advanced presentations were less successfully managed. Biopsy alone or palliative bypass procedure could only be offered and the survival rate was dismal.

CT and barium features of gastrointestinal and peritoneal tuberculosis.

The radiological features in barium gastrointestinal studies and computed tomographic (CT) examinations of 22 consecutive cases of proven peritoneal and/or intestinal tuberculosis were analyzed in order to highlight the radiological features which could provide ready identification of the disease. There were 15 cases of intestinal tuberculosis and 7 cases of peritoneal tuberculosis and 3 patients had both. The commonest location of intestinal tuberculosis was the ileocecal region (N=10) which occurred in association with colonic or ilea] disease. Bowel wall thickening in CT was largely asymmetrical but minimal and symmetrical wall thickening occurred with peritonitis. Luminal narrowing with or without mucosal tethering were seen in both CT and Barium studies. Peritoneal TB had either high density ascites with smudge or nodular omental surface with a thickened omental lining. Also detected was fibrinous dry peritonitis with thickened mesenteric tissue. Lymphadenopathy in the peripancreatic, mesenteric or paracaval were common to both intestinal or peritoneal tuberculosis (21 out of 22). Fifty percent of the patients showed some lymph nodes with necrotic centers. The differential diagnosis included malignant peritonitis and intestinal or mesenteric carcinoid. The study shows that a combination of barium gastrointestinal study and computed tomography can provide distinct features which could strongly suggest the diagnosis of intestinal or peritoneal tuberculosis.

Peritoneal lithiasis and cliptomas following laparoscopic cholecystectomy.

A review was made of five patients with post-laparoscopic cholecystectomy peritoneal soiling with clips and/or stone. Three patients were symptomatic with recurrent abdominal pain or back pain. One of these had clips alone, one had clips and stone and the third had stones alone. The location of the stones in the pelvis and right iliac fossa created confusion in the diagnosis, simulating ureteric calculi and appendicitis, respectively. Surgical operation revealed granulomas around the stones. The consequences of peritoneal clips is not yet known. However, peritoneal lithiasis and potential complications should be considered as a differential of abdominal and pelvic calculi.

Mammographic features of breast tuberculosis: the skin bulge and sinus tract sign.

Six cases with bacteriologically and/or histologically proven breast tuberculosis were analysed out of 1152 consecutive mammograms performed. The objective was to identify some factors that may facilitate pre-operative mammographic and ultrasonographic diagnosis of breast tuberculosis. Nipple retraction and coarse stromal texture occurred in all six cases. In five cases there was an ill-defined breast mass, skin thickening, and a reduction in size of the affected breast. A unique finding was a sinus tract connecting the breast density to a localized skin thickening and bulge which occurred in only two cases. Ultrasonography showed cystic masses. The incidence of breast tuberculosis in the studied population was 0.52%. A mammographic demonstration of a dense tract connecting an ill-defined breast mass to a localized skin thickening and bulge (skin bulge and sinus tract sign) is strongly suggestive of tuberculous breast abscess. Change in shape and outline of the breast mass can be seen in the standard breast views.

Radiographic features of lobar agenesis of the liver.

PURPOSE: Our aim was to describe the radiographic features of lobar agenesis of the liver. MATERIAL AND METHODS: Six patients with lobar agenesis of the liver, 5 right- and one left-sided, are presented. CT was used to confirm diagnosis. Chest radiography, barium meals, and urograms were also analyzed. RESULTS: In right-sided agenesis, the following were observed: a) hammock or U-shaped deformity of the stomach; b) colonic interposition of the diaphragm (Chilaiditi's syndrome); and c) reversal of the cranial orientation of the colonic hepatic flexure compared to the splenic flexure. The right kidney was higher in position than the left in both right- and left-sided lobar agenesis. CONCLUSION: Our radiographic findings can provide a multidisciplinary approach in the identification of this anatomic anomaly.

Early detection of breast cancer: Report from King Khalid University Hospital.

Eighteen mammographically detected, nonpalpable breast lesions, comprising 14 parenchymal and four ductal lesions, were studied. Kopan's localization needle was used, guided by an alpha-numerical plate in the parenchymal lesion and ductography with methylene blue dye for the ductal lesions. Three (two stellate lesions, one microcalcification) out of 14 (21%) were positive for invasive cancer. The rest showed ductal epithelial hyperplasia and fibrocytosis disease. All the ductal lesions were correctly localized and confirmed pathologically as papillomata. The three positive cases for carcinoma were under 50 years of age and two were under 40 years of age. Cognizance will have to be taken of the age group involved in determining the lower limit for breast cancer screening when implemented. Localization of intraductal lesions with methylene blue dye facilities surgical identification.

Comparative study of plain abdominal films and small bowel enema in clinically unclear cases of small bowel obstruction.

A study was undertaken to compare the usefulness of plain abdominal X-rays (PABR) and small bowel enema (SBE) in evaluating cases of clinically unclear small bowel obstruction. The PABR of the patients taken just before the small bowel enema were compared to the films of the SBE. Fifty-two out of 76 were eventually operated on. The results show the gross limitations of PABR in excluding the presence of small bowel obstruction. The sensitivity and negative predictive value of SBE in identifying or excluding obstruction were 100% each, while the corresponding values of PABR were 42 and 40%. However, the margin of specificity and positive predictive values were narrow; 94 and 97 percent in SBE and 86 and 88 in PABR. SBE was also superior in identifying the cause and location of obstruction. In conclusion, due to the specificity of PABR it will remain the first line of investigations in suspected intestinal obstruction. However, its limitation in excluding the presence of obstruction cannot be overemphasized. The SBE confirms or excludes obstruction promptly and should be applied as the most accurate evaluation.

Accuracy of hysterosalpingography and laparoscopic hydrotubation in diagnosis of tubal patency.

OBJECTIVE: To compare the diagnostic accuracy of two methods of assessment of tubal patency, viz, hysterosalpingography (HSG) and laparoscopic hydrotubation. DESIGN: One hundred four infertile women who were investigated with both HSG and laparoscopy in King Khalid University Hospital were selected for the study. Complete history of factors that may predispose to tubal occlusion was obtained. Patients with problems of ovulatory failure or poor semen analysis that may contribute to their infertility were excluded. RESULTS: The overall agreement between the two methods was 62.5%. However, the diagnostic accuracy of the two methods differed significantly. CONCLUSION: It would appear that laparoscopic hydrotubation, despite its invasive nature, had an edge in diagnostic accuracy when compared with HSG. It would be advantageous to subject patients in whom HSG has shown tubal blockage to laparoscopy or any of the newer techniques of hysteroscopy or sonographic hydrotubation.

Right aortic arch: CT. diagnosis.

Computer Tomography (CT) can be helpful in the detection and diagnosis of aortic arch malformations, particularly the retro-oesophageal right side aortic arch with aberrant left subclavian artery. Three adult Saudi patients with this anomaly where recently encountered and are herein presented. All the three patients had CT scans with clear demonstration of the right aortic arch. CT can confirm the presence of this aortic arch anomaly suspected from plain chest radiographs or can detect the vascular anomaly when the radiographs suggest the presence of a mediastinal mass. The condition of congenital anomalous right aortic arch is also briefly discussed.

Radiologic and sonographic evaluation of intra-abdominal abscesses in a Nigerian population.

A prospective study to evaluate the radiologic and sonographic features of intraabdominal abscesses in a mixed Nigerian population was undertaken. 30 patients with suspected abscesses were studied and a total of 70 abdominal abscess sites were confirmed at surgery or during autopsy in 22 patients. The more common abscess sites were the paracolic and pelvic areas. Typhoid enteritis, perforated duodenal ulcer and septicaemia were the aetiological factors in 54%, 13.6% and 13.6% respectively. The more common radiological feature was that of extraluminal gas vesicles and relatively echo free collections were identified during ultrasound. Poor prognosis was associated with typhoid enteritis, multiple abscess sites and acute renal failure.

A comparative ultrasound and plain abdominal x-ray: Evaluation of non-classical clinical cases of appendicitis.

A prospective study of 109 patients with non-classical symptoms of appendicitis using the standard ultrasound (US) machine and plain abdominal x-rays demonstrated that US was superior to plain x-ray with a sensitivitiy, specificity and overall accuracy of 89%, 96% and 91%, respectively as compared with plain x-ray with 48%, 93% and 67% respectively. The negative appendectomy rate was 7%. In the alternative diagnosis, plain x-ray was superior to US due to the prevalence of intestinal diseases, ureteric calculi and basal pneumonia which were best shown in plain x-rays. US was, however, most useful in detecting female pelvic pathology. It is hoped that with improved imaging expertise and the appication of high resolution US machine a higher sensitivity and accuracy can be achieved. US is therefore recommended as the first line in the imaging of non-classical cases of appendicitis. However, in areas where enteric diseases and urinary calculus are endemic, it is prudent to perform both ultrasound and plain abdominal x-rays while the patient is in the radiodiagnostic department.