Cholecysto-urachal fistula.

The urachus is an embryonic remnant that connects the primitive bladder to the allantois. Multiple urachal anomalies have been described, including the urachal sinus, urachal cyst, patent urachus, and urachal diverticulum. We describe an unusual case in which a patient with urinary tract infection and dysuria was ultimately found to have urinary gallstones from a urachal connection with the gallbladder.

CT of the duodenum: an overlooked segment gets its due.

Abdominal computed tomography (CT) is frequently performed to evaluate gastrointestinal pathologic conditions, and the majority of the gastrointestinal radiology literature has concentrated on the colon, stomach, and distal small bowel. In a description of CT findings of duodenal pathologic conditions, congenital, traumatic, inflammatory, and neoplastic diseases are presented. Congenital duodenal anomalies such as duplications and diverticula are usually asymptomatic, while annular pancreas and malrotation may manifest in the 1st decade of life. CT plays a vital role in the diagnosis of traumatic duodenal injury. Primary inflammatory processes of the duodenum such as ulcers and secondary involvement from pancreatitis can reliably be diagnosed at CT. Infectious diseases of the duodenum are difficult to diagnose, as the findings are not specific. While small bowel malignancies are relatively rare, lipoma, adenoma, and adenocarcinoma, as well as local extension from adjacent malignancies, can be diagnosed at CT. Careful CT technique and attention to the duodenum can result in reliable prospective diagnoses.

Multiplanar helical CT enterography in patients with Crohn's disease.

OBJECTIVE: The purpose of this study was to assess the feasibility and usefulness of helical CT with multiplanar reformations in revealing complications in patients with Crohn's disease. SUBJECTS AND METHODS: Twenty-two patients with Crohn's disease and clinically suspected complications underwent helical CT enterography. The imaging protocol began with the administration of a large volume (1600 ml) of oral contrast material followed by helical scanning with axial and multiplanar two-dimensional coronal projections. Three independent observers assessed the adequacy of bowel opacification and the contribution of two-dimensional coronal projections to the interpretation of axial images. CT enterography was compared with conventional barium studies in 14 patients. Statistical analysis included repeated measures analysis of variance, the Wilcoxon signed-rank test, and the McNemar test. RESULTS: The large oral contrast medium dose was well tolerated and provided optimal bowel opacification in 21 of 22 patients. The addition of multiplanar to conventional axial images did not reveal additional abnormalities; however, multiplanar imaging significantly improved observers' confidence in their interpretation of imaging and in their assessment of the extent of bowel wall thickening (p < .01). Interobserver agreement was 78%. Findings on helical CT were comparable with those on barium studies in nine of 14 patients, superior to those on barium studies in four patients, and inferior in one patient. CONCLUSION: CT enterography is a useful technique for bowel imaging. In patients with complicated Crohn's disease, multiplanar imaging improves confidence in assessing the presence and extent of disease. CT enterography is complementary and often superior to conventional barium studies.

Pancreatic duct stricture length at ERCP predicts tumor size and pathological stage of pancreatic cancer.

OBJECTIVE: To determine whether findings on endoscopic retrograde cholangiopancreatography (ERCP) could provide useful prognostic information in resectable pancreatic cancer. METHODS: We retrospectively identified 18 patients with resectable pancreatic cancer (defined as no evidence of metastatic disease or vascular involvement on CT scan) who had undergone ERCP prior to an attempt at curative resection between 1991 and 1996. Common bile duct and pancreatic duct stricture lengths were measured on ERCP and compared with the size of the resected tumor. Magnification was controlled for by comparison with endoscope diameter. Stricture length was plotted against actual tumor size, and a correlation analysis was performed. RESULTS: Pancreatic duct stricture length measured on ERCP correlated with both size (p < 0.001) and stage (p < 0.002) in resectable pancreatic cancer. CONCLUSIONS: ERCP may provide useful preoperative prognostic as well as diagnostic information in pancreatic cancer.

The use of helical CT and CT angiography to predict vascular involvement from pancreatic cancer: correlation with findings at surgery.

OBJECTIVE: The purpose of this study was to test the accuracy of helical CT with and without CT angiography to predict vascular involvement from pancreatic cancer and correlate the resultant images with findings at surgery. SUBJECTS AND METHODS: Helical CT and CT angiography was done in 84 patients who had adenocarcinoma of the pancreas to refine an integrated CT angiography protocol. Of these patients 38 underwent radical pancreatoduodenectomy. Vessel integrity of the superior mesenteric artery, superior mesenteric vein, and portal vein was assessed prospectively on both axial CT scans and CT angiograms and correlated with findings at surgery and in particular with the ability of the surgeon to dissect the tumor from these vessels along the vascular planes. RESULTS: CT angiograms were obtained in 82 (98%) of 84 studies. Of the 38 patients who underwent radical pancreatoduodenectomy, resection was aborted in 11 (29%) because of vascular encasement, Compared with axial CT images, CT angiography was more accurate at revealing unresectable cases. In all but one of 11 patients with vessel encasement (narrowing of the lumen) revealed on CT angiography, the lesion was unresectable. Vessel encasement was shown in only two of these 11 patients on axial CT images (of these two patients, one underwent tumor resection). The negative predictive value of a resectable tumor was 96% for CT angiography and axial helical CT compared with 70% for axial helical CT images alone (p = .021). CONCLUSION: Helical CT with CT angiography of the pancreas provides useful information about local vascular involvement from pancreatic carcinoma. Compared with conventional axial helical CT, the addition of CT angiography improves radiologists' ability to predict the resectability of pancreatic tumors.