Solitary hepatic cyst and benign bile duct polyp: a heretofore unheralded association.

Solitary hepatic cysts are uncommon lesions that can produce jaundice by extrinsic compression on the extrahepatic biliary tree. In two recent cases of solitary hepatic cyst with jaundice, an intraluminal polypoid adenoma that obstructed the common hepatic duct was discovered. Concurrence of these two unusual lesions suggests that they may be associated. The importance of recognizing this association is illustrated by two case reports. In case 1, extrinsic compression by the cyst on the common hepatic duct was identified as the cause of jaundice at the initial operation. In case 2, choledocholithiasis was the initial explanation for the jaundice. In both cases, palpation and exploration of the proximal bile ducts with probes and catheters failed to discover the polyp. However, jaundice persisted postoperatively in both cases, and subsequent contrast radiography revealed an intraluminal filling defect in the common hepatic duct. In both cases, reoperation was required, and a benign bile duct polyp was discovered and excised. Thus, the presence of jaundice in a patient with a cystic hepatic mass should suggest the possibility of a concurrent bile duct polyp. Awareness of this possibility should permit recognition of such a polyp at initial operation.

Ultrasonography in the diagnosis of a type 1 choledochal cyst.

We have described an adult patient with a type 1 choledochal cyst and without jaundice. Ultrasonography demonstrated a cystic mass in the right upper quadrant and dilated bile ducts.

Ultrasonic diagnosis of obstructed renal duplication and ureterocele.

The diagnoses of complete obstruction in a duplicated renal collecting system and ureterocele can be made with a high degree of confidence by ultrasound. Two children presenting with abdominal masses were examined by gray scale ultrasonography which demonstrated large cystic masses dorsal to and displacing the lower pole of the kidney ventrally and laterally. In one patient the dilated ureter terminated in a ureterocele. Ultrasonography is the appropriate imaging modality for this disease process, though it generally becomes the complementary study to excretory urography in the diagnosis of an obstructed duplicated system. The dilated pelvis and ureter can be imaged to ultrasonography even when their presence is only implied on an excretory urogram. Finally, the cystic nature of a ureterocele, as well as its relationship to the ureter and bladder, makes ultrasonography an ideal technic for evaluating this anomaly.

Differentiating empyemas and peripheral pulmonary abscesses: the value of computed tomography.

In 13 patients, conventional radiographic techniques and clinical histories were not sufficient to determine whether a peripheral cavitary lesion was an abscess or an empyema. However, after computed tomography (CT), eight patients were diagnosed as having abscesses and five as having empyemas. Abscesses had an irregular shape and a relatively thick wall which was not uniformly wide and did not have a discrete boundary between the lesion and lung parenchyma. In contrast, empyemas had a regularly shaped lumen, a smooth inner surface, and a sharply defined border between the lesion and lung. CT studies can help to distinguish between empyemas and abscesses, and treatment can be started sooner in difficult cases.

Ultrasound patterns of disorders affecting the gastrointestinal tract.

A mass associated with the gastrointestinal tract was detected by sonography in 33 patients. Etiologies included primary or metastatic tumor; intussusception; inflammation secondary to bowel infarction, pancreatitis, or irradiation; and a dilated, fluid-filled gut related to retained gastric contents, obstruction, ileus, or an ileal bypass. Mesenteric or omental changes were identified with inflammation and frequently with metastatic disease. The diagnosis was confirmed by repeat sonography, abdominal radiography, barium examination of the small bowel, computed tomography, surgery, or autopsy. Ultrasound patterns are characteristic in tumor, intussusception, and inflammation; specific features allowing differentiation between tumor and inflammation are described. Colonic haustra, valvulae conniventes, or bowel contours and peristalsis on real-time sonography are helpful in identifying fluid-filled bowel loops.

Lymphoid follicular pattern of the colon in adults.

The clinical and radiographic findings of the colonic lymphoid follicular pattern in 37 adults aged 20-79 years were evaluated. An incidence of 13% was found on review of 100 consecutive double-contrast barium enemas. Usually, the presence of multiple 1-3 mm diam, uniform-size nodules is sufficiently characteristic to make a presumptive diagnosis on these radiographic criteria. The nodules are often not visible endoscopically. The clinical data suggest that that the lymphoid follicular pattern is usually of no clinical significance in adults. In most patients, its radiologic pattern can be distinguished from entities such as familial polyposis and early Crohn's disease, thus sparing the patient unnecessary further diagnostic evaluation.

Type II choledochal cyst: ultrasonographic appearance.

The ultrasonic findings in a rare Type II choledochal cyst are described. In patients with a right upper quadrant mass in whom the clinical, ultrasonic, or radiographic findings are atypical for other etiologies, this diagnosis should be considered.

The spectrum of small bowel melanoma.

Twenty-one patients with documented secondary small bowel involvement by malignant melanoma are reviewed. Roentgen mainfestations are discussed and illustrated. A vigorous diagnostic approach emphasizing enteroclysis is described. Clinical awareness and aggressive radiologic investigation are providing these patients with earlier surgical and adjuvant therapy, which appears to be leading to increased length of survival.

Double contrast barium enema in Crohn's disease and ulcerative colitis.

Double contrast barium enema examinations in 24 patients with Crohn's disease of the colon and 29 patients with ulcerative colitis were reviewed without knowledge of the clinical diagnosis. The radiologic diagnosis of Crohn's disease agreed with the clinical diagnosis in 98% of patients. In this condition the most common radiologic findings were discontinuous or asymmetric disease (88%) and discrete ulcers (67%) often on a normal mucosa. The latter are characteristic of early Crohn's disease and may enable the radiologist to be the first to suggest the diagnosis, particularly when both sigmoidoscopy and small bowel examination are normal. Of the patients with ulcerative colitis, a positive radiologic diagnosis was made in 83% on the basis of a granular mucosal pattern (79%) and continuous distal involvement (86%). The high accuracy of the double contrast technique, especially in Crohn's disease, and the relative specificity of the signs that it can demonstrate suggest that this is the preferred examination in the radiologic evaluation of inflammatory bowel disease.

Synchronous and metachronous squamous cell carcinomas of the head, neck and esophagus.

Thirty-four (1%) of 3,287 patients with squamous carcinoma of the head-neck developed carcinoma of the esophagus. The clinical and radiological importance of this relationship is emphasized. Since there is an increased incidence of esophageal carcinoma in this group, perhaps all such patients should have an annual esophagogram.

Acute gastrointestinal hemorrhage: the changing role of barium examinations.

The emergency evaluation of a patient with acute life-threatening gastrointestinal hemorrhage requires the coordinated efforts of medical, surgical, and radiologic personnel. In most patients with an acute upper gastrointestinal hemorrhage, endoscopy represents the primary diagnostic procedure. Arteriography may follow, depending on the identification of the lesion at endoscopy or the need for therapy through the vascular catheter. Arteriography should precede endoscopy when bleeding is massive or the clinical situation suggests that therapy by a catheter must be instituted on a more urgent basis. When personnel are available to perform endoscopy and arteriography, the barium examination of the upper gastrointestinal tract is best postponed for a few days until the patient can be stabilized completely. In the patient with massive red rectal bleeding and a negative nasogastric aspirate, the arteriogram is clearly the procedure of choice for the emergency diagnostic evaluation. Bleeding diverticular and vascular ectatic lesions can be diagnosed only by arteriography and treatment can usually begin immediately by a catheter infusion of vasopressin. Colonoscopic and barium enema examinations of the acutely bleeding patient are not reliable. In addition, the presence of barium in the colon interferes with arteriography for a number of hours. The barium examination of the colon should be performed at some time during the hospitalization to exclude other possible bleeding lesions and to provide a better overall anatomic assessment of the colon. Both the retrograde and antegrade small bowel enemas are useful in detecting obscure small bowel bleeding lesions that occasionally present as a massive lower gastrointestinal hemorrhage.