Intramural pseudodiverticulosis of the esophagus.

Esophageal intramural pseudodiverticulosis (EIPD) is a rare condition seen in the elderly, with a male-to-female ratio of 3:2. Multiple small outpouchings occur in the submucosa of the esophageal wall, caused by dilation of the excretory ducts of the mucus glands. This disorder may be associated with gastroesophageal reflux, motility disorders, candidiasis, or other conditions. Inflammation, resulting in periductal fibrosis and compression of the duct orifices, may be a causative factor. Usually, EPID presents with progressive dysphagia related to esophageal stenosis or strictures in the great majority of patients. Radiologic examination is more sensitive than endoscopy in detecting these tiny saccular diverticula in the esophageal wall. They often are noted to disappear after esophageal dilation, but may persist asymptomatically in some patients. We report two cases of dysphagia associated with reflux and Candida infection in elderly patients. The diagnosis of EIPD was made, and both patients were treated successfully. A review of the available literature suggests that EIPD may be missed easily because of subtle endoscopic and radiologic changes, but that once diagnosed, conservative management leads to satisfactory control of the symptoms.

Radiological treatment of retained bile duct stones following recent surgery using glucagons.

BACKGROUND: Retained common bile duct (CBD) stones pose an occasional problem following ductal exploration, in spite of completion cholangiography or choledochoscopy. We present a method for treating retained stones in the Radiology Department by biliary lavage via a transcystic tube (TCT) or a T-tube, after intravenous administration of glucagon. METHODS: A TCT or T-tube is inserted following CBD exploration for multiple intrahepatic stones or when stones are fragmented to facilitate removal or flushing into the duodenum. A tube cholangiogram is performed on the 1st postoperative day. If any retained stones are encountered, 1 mg glucagon is administered intravenously and saline irrigation through the tube is done under fluoroscopic control, allowing the stone to pass to the duodenum. The cholangiogram is repeated 10-14 days later, before removing the tube. RESULTS: In case 1, transcystic CBD exploration was performed. Two stones were crushed and flushed into the duodenum. TCT cholangiography the following day. showed a 5-6-mm fragment causing complete obstruction. Following the use of glucagon and irrigation, the stone was observed passing into the duodenum, causing a brief mild episode of pain. In case 2, laparoscopic choledochotomy was performed to remove seven large stones. Completion choledochoscopy was satisfactory. T-tube cholangiography identified a small stone in the CBD, which was cleared with the help of glucagon. CONCLUSION: The current standard treatment for retained stones is endoscopic sphincterotomy. This is associated with morbidity, mortality, and significant additional cost. This new technique is a simple and safe alternative for retained CBD stones, most of which as small stones or fragments. Because glucagon causes intense relaxation of the sphincter of Oddi, the procedure should not take much longer than a routine tube cholangiogram. The safety of glucagon makes it possible to repeat the procedure if necessary.

A comparison of two or three radiographic views in the diagnosis of skull fractures.

The aim of the study is to determine whether a two rather than a three-view skull series is adequate for diagnosis of a skull fracture given a reliable history of the site of trauma. The radiographs of 50 patients who were diagnosed and managed as having sustained skull fractures were randomly mixed with 200 normal skull series and viewed independently by three observers. For all the film series viewed (a total of 1500 for the three observers), the diagnostic confidence level for two films was 94.4%, and for three films 94.6%. Of a total of 150 skull fracture series viewed as two films, 87 (58%) were correctly diagnosed with a confidence level of 92.7%. When viewed as three films, 92 (61.3%) were correctly diagnosed with a confidence level of 93%. Combined with analysis of false-positive and false-negative results, no statistical difference could be detected between a two or three film skull series. A two-view skull series has no statistically deleterious effect on either diagnostic accuracy or confidence of interpretation when compared with a three-view series given an accurate clinical history.

Technical report: an alternative mechanical technique of pseudoaneurysm compression therapy.

Graded manual compression therapy under ultrasound guidance has become the standard first line treatment of post-catheterization femoral pseudoaneurysms. Although effective, this treatment is often poorly tolerated by both patient and operator. We describe a new mechanical technique which has proven successful in our department, and is well tolerated by both patients and staff.