Contrast-enhanced magnetic resonance imaging for the detection of acute haemorrhagic necrotizing pancreatitis.

Eleven piglets with haemorrhagic necrotizing pancreatitis and nine piglets with oedematous pancreatitis were imaged using a multi-breath-hold TurboFLASH (TR 6.5 ms, TE 3 ms, TI 300 ms, flip angle 8 degrees , three slices) pre-excited T1-weighted sequence with an IV bolus injection of gadopentetate dimeglumine (Gd-DTPA, 0. 3 mmol/kg) as a contrast agent to show dynamic contrast enhancement of the pancreas by MRI. All piglets were imaged according to the same protocol before inducing the disease. Following the IV Gd-DTPA bolus, time-enhancement curve of the pancreas during haemorrhagic necrotizing pancreatitis was significantly lower than during oedematous pancreatitis. The enhancement curves for the healthy piglets and piglets with oedematous pancreatitis did not differ significantly. Each piglet served as its own control. Because the results of this initial study are similar to those obtained with contrast-enhanced CT, we conclude that our results may encourage further clinical trials, and contrast-enhanced dynamic MRI may be an alternative to the established method of CT for diagnosing acute haemorrhagic necrotizing pancreatitis.

Dynamic high-field MR imaging in experimental porcine acute pancreatitis.

The effects of acute pancreatitis on MR imaging signal intensities (SIs) were determined in an experimental study at 1.0 T. Oedematous pancreatitis was induced in 9 piglets and haemorrhagic pancreatitis in 11 piglets. Each animal served as its own control for MR imaging before and after induction of pancreatitis. T1-weighted spin echo (450/15 ms) and dynamic turbo FLASH (flip angle 8 degrees) sequences were used without contrast medium in testing the stability of the SI measurements. There was no significant difference in the SI-versus-time curves of the pancreas in piglets with oedematous and haemorrhagic pancreatitis. However, the difference in mean SIs between healthy and diseased piglets was significant. Thus, although non-contrast MR may be useful in the diagnosis of acute pancreatitis, it does not distinguish between oedematous and haemorrhagic pancreatitis.

Spontaneous rupture and functional state of the esophagus.

Esophageal function was investigated after 1 to 8 years in five consecutive patients surviving spontaneous esophageal rupture (Boerhaave's syndrome) and treated by suturation. Only one patient was symptom free and had almost normal esophageal function as judged by manometry, 24-hour pH monitoring, endoscopy, and barium swallow. In the other four patients reflux symptoms and a severe functional disturbance of the esophagus were observed. In four patients the manometry revealed a lack of propulsive peristaltic movements and esophageal muscular incoordination (particularly in the upper part of the esophagus) closely mimicking those seen in the nonspecific esophageal motility disorder. In 24-hour intraesophageal pH monitoring a pathologic gastroesophageal reflux with long-lasting single reflux periods was observed, suggesting poor esophageal clearance. Also endoscopic and histologic signs of reflux esophagitis were seen in the same four patients. In contrast, lower esophageal sphincter pressure was normal in all five survivors. It is concluded that patients with spontaneous esophageal rupture have a severe disturbance of esophageal motility. The concomitant reflux esophagitis may be caused primarily by the esophageal motility disturbance, which may also contribute to the origin of the rupture.

When is routine operative cholangiography necessary? An evaluation of 200 consecutive patients operated on for gallbladder stones.

Operative cholangiography (OC) was performed during open standard cholecystectomy in 195 of 200 consecutive patients. The cholangiography was considered suspicious for choledochal stones in 28 patients (14%). Both choledochotomy and choledochoscopy were carried out. Stones in the biliary tree were found in 17 patients and in 11 cases choledochotomy was negative. Cholecystectomy was performed on an emergency basis in 46 patients, 15 of them underwent choledochotomy and in 11 (24%) bile duct stones were found. In 154 electively operated patients six (4%) had choledochal stones. Based on preoperative history choledochal stones were suspected in 30 electively operated patients but only eight had stones in the biliary tree at the time of operation. The percentage of false positive cholangiograms was 6% in the whole material, and unsuspected choledochal stones were diagnosed in 5% respectively. It is recommended that operative cholangiography should be performed routinely in patients subjected to emergency cholecystectomy. In elective operations selective use is acceptable.

Acalculous cholecystitis after bone marrow transplantation in adults with acute leukaemia. Case report.

In three adults with acute leukaemia, acalculous cholecystitis was diagnosed with ultrasonography soon after bone marrow transplantation. The clinical picture of cholecystitis was progressive, and cholecystectomy was performed in all cases despite anaemia, granulocytopenia and thrombocytopenia. Postoperative recovery was uncomplicated.

Pitfalls in the diagnosis of drug smuggler's abdomen.

Narcotics "body packing" can be detected in abdominal X-rays by the ring shadow caused by air trapped in the packs. In a series of 82 cases admitted for abdominal X-ray in Helsinki, Finland, in 1982 through 1988, we encountered 9 (11.0%) true positives, 3 (3.6%) false positives, and 1 (1.2%) false negative. The false positives were due to the constipation often associated with the narcotics abuse. The false negative X-ray diagnosis was attributable to an inexperienced radiologist. False negatives may also be associated with packets containing marijuana, packs with few wrappings, aluminum-foil coated packs, and machine-packed narcotics. Searching for trapped air in radiographs, repeated X-raying by an experienced radiologist, use of computed tomography, or combined urinary drug screening may be applied to diminish false findings and to avoid unnecessary arrest for the purpose of fecal screening over several days.

Radiation exposure during percutaneous nephrostomy.

Radiation doses of radiologists, assistants and patients during 21 percutaneous nephrostomies (PN) (including 11 unilateral and 5 bilateral procedures) were measured using an area-exposure meter and thermoluminescent dosimeters. The mean fluoroscopy time per PN was 12 min and the mean product of air kerma and the cross-sectional area of the fluoroscopic beam was 8.0 (range 0.41-24) Gycm2. Doses to the radiologists and assistants were generally modest, and the yearly dose limits of ICRP will not be exceeded in practice. The doses to the radiologist's fingers were found to be the most restrictive in this study. Regarding the mean dose to the radiologist's fingers (190 muGy), the yearly dose limit of 500 mSv would be exceeded after about 2600 PNs provided that his fingers are not otherwise exposed. With the maximal finger dose of 1100 muGy, this would occur after about 450 yearly PNs.

Ultrasound guidance for pericardiocentesis.

Sonographic guidance with 41 punctures and 38 catheterizations was employed in 68 patients. The approach was either intercostal or subxiphoid. Most punctures were performed with a 1.4-mm-thick plastic-sheathed cannula after local anesthesia. Complications were observed in 7 patients. In one patient a catheter introduced with a movable core-type guidewire pierced the right ventricle wall with uneventful recovery after surgery. Intercostal drainage caused pleural pain in 2 patients, and in 2, leakage to the pleural space. Two patients with heart transplants had severe bradycardia and drop of blood pressure, one after needle drainage and the other during guidewire manipulation. Direct monitoring generally ensures a correct position of the instruments and hazards to adjacent organs can be avoided. In small effusions a simple needle aspiration with a plastic-sheathed cannula is safer than catheter drainage.

Vascular changes of pancreatic ducts and vessels in acute necrotizing, and in chronic pancreatitis in humans.

Five patients with severe acute pancreatitis (AP) underwent subtotal pancreatectomy, and six patients with advanced chronic pancreatitis (CP) were subjected to pancreatic resection. Microangiography and histological studies were performed on the resected pancreata. All patients with AP had histologically verified necrotizing pancreatitis. Pancreatic ducts in the necrotic areas had severe inflammation in their walls and a decrease in their vascularity. The ductal walls of CP patients were indistinguishable from the surrounding fibrosis and the vascular supply of the ducts was markedly diminished. The vessels were reduced in number, and their calibers varied considerably. Ductal ischemia in connection with AP and CP is discussed.

Diagnostic evaluation and aggressive surgical approach in bleeding pseudoaneurysms associated with pancreatic pseudocysts.

Hemorrhage is an uncommon but serious complication of pancreatic pseudocysts. When gastrointestinal bleeding or intra-abdominal hemorrhage is associated with a pancreatic pseudocyst and the usual sources of bleeding are not detected by endoscopy, the rupture of a pseudoaneurysm inside the pseudocyst should be suspected. We present 13 cases, 11 associated with chronic and 2 with late complications after acute necrotizing pancreatitis. On the basis of sonographic findings, bleeding site was suspected in 8 of 11 patients (73%). Computed tomography (CT) was performed on 10, and bleeding was suspected in 8 (80%). The pseudoaneurysm itself was detected by CT in one and by ultrasonography in none. Visceral angiography was performed on five patients, and the pseudoaneurysm was evident in all. External drainage with arterial ligation was done as a primary operation in five patients; four of them later underwent pancreatic resection because of rebleeding. In eight cases pancreatic resection was the initial operation; none of these patients continued to bleed or needed reoperation because of the same pseudoaneurysm. There were no intraoperative deaths, but one patient died postoperatively. Aggressive diagnostic evaluation and surgical approach are associated with a reduction in mortality and morbidity in this serious complication of pancreatic pseudocysts.

Efficacy and complications of the Nd:YAG laser in partial nephrectomy: experimental study in piglets.

Twenty-four partial nephrectomies were performed in 18 piglets using either the combination Nd:YAG laser technique (contact and noncontact) or a steel scalpel. Additional haemostasis was attempted with ligatures. Blood loss, operation time, and number of ligatures were compared in the two treatment groups. Twelve piglets had a two-week follow-up. The mean blood loss with the laser was 72 +/- 10 g and 83 +/- 13 g with the steel scalpel (no significant difference). The resection time until complete haemostasis was 9.8 +/- 0.9 min with the laser and 14.3 +/- 1.3 min with the steel scalpel (p = 0.0076). The number of ligatures needed for complete haemostasis was 2.8 +/- 0.4 with the laser and 7.5 +/- 1.0 with the steel scalpel (p = 0.0051). Three piglets in the steel scalpel group developed urinomas. There were two perirenal abscesses, one in each group. In the steel scalpel group there was one intussusception. In conclusion, it seems that the combination Nd:YAG laser method offers no definitive advantage over the standard technique for partial nephrectomies in the pig.

Intramural ureteric injury due to acute dilatation.

The effect of balloon dilatation of the ureteric orifice and the intramural ureter was evaluated histologically and radiologically in eight piglets. The distal part of the ureter was dilated from its normal calibre of 4F to 12F. Four weeks after the procedure obvious histological signs due to the preceding dilatation were seen in seven of the eight ureters. In simultaneous radiological studies two ureters showed massive and one slight dilatation and two ureters showed vesicoureteral reflux. The results suggest cautious use of dilatation. Small calibre ureterscopes without ureteric dilatation should be preferred.

Microangiographic changes of the pancreatic ducts in experimental chronic pancreatitis.

Chronic pancreatitis was induced in eight piglets by dividing all pancreatic attachments to the duodenum. Five piglets served as controls. The animals which were operated on were autopsied six weeks thereafter. Ductography and microangiography were performed. Histological preparations of pancreatic tissue were made. All of the animals which underwent operation developed histologically verified chronic pancreatitis. Ductography revealed the main ducts and the side branches to be considerably dilated. They also exhibited variations in calibre and sudden obstructions. Two animals had a large non-infected pseudocyst. No communication between the cyst and the main duct could be demonstrated by ductography. No pancreatic calcifications were seen. The vasculature of the ductal plexuses seems to be derived from interlobular arteries. The animals with chronic pancreatitis had marked diminution of the vascular supply of the ducts. The changes in ductal vascularity correlated with the severity of the histological changes to the pancreas and may, thus, in part explain the progress of pancreatitis.

Percutaneous drainage of periappendiceal abscess in a patient with acute leukemia. Case report.

In a 24-year-old man with acute lymphatic leukemia, acute appendicitis after induction of chemotherapy led, with minimal clinical signs, to perforation and periappendiceal abscess (verified with CT and US-guided needle aspiration). Percutaneous drainage was performed for 11 days and appendectomy 3 days later. Recovery was uncomplicated and cytostatic therapy was resumed.

Experimental chronic pancreatitis in the pig.

Chronic pancreatitis was induced in 22 piglets by dividing all pancreatic attachments to the duodenum; five sham-operated piglets served as controls. Two piglets died of postoperative complications. The animals were autopsied 2, 4, or 6 weeks postoperatively. All operated animals developed chronic pancreatitis. Concomitant with the development of interstitial fibrosis, an increasing progressive atrophy of the exocrine parenchyma occurred, with preservation of the islets of Langerhans. This atrophy and fibrosis were considerable already after 2 weeks. In one piglet only there was some acute inflammation and fat necrosis, whereas all showed at least moderate chronic inflammation, which did not change with time. The growth of the piglets stopped, and all had diarrhoea, which was thought to reflect exocrine insufficiency. Two animals (9%) developed a large pancreatic pseudocyst, and all animals had wide pancreatic ducts. The endocrine function was undisturbed. Intravenous glucose tolerance tests showed that the animals did not become diabetic. This model is appropriate for the study of experimental pancreatitis.

Microangiography and dynamic computed tomography in experimental chronic pancreatitis in the pig.

Chronic pancreatitis was induced in 22 piglets by dividing all pancreatic attachments to the duodenum. Ten piglets served as controls. The animals were subjected to dynamic computed tomography (CT) two, four or six weeks after operation. Microangiography was also performed on the pancreas two, four or six weeks after operation, following dynamic computed tomography. Microangiography revealed significant changes in the vasculature in advanced chronic pancreatitis. The arteries and arterioles were fewer than normal, their walls were thickened and their diameters exhibited variation. The capillary network was loose and the capillaries were not as well filled as in healthy animals. Contrast enhancement of the pancreas was, however, similar in all experimental animals to that in the healthy controls. It was concluded that the morphological changes seen in chronic pancreatitis histologically and on microangiography could not adversely affect contrast-enhanced CT because there were no changes in the function of the capillary network. On the basis of these results, dynamic CT should give no more information than CT with intravenous contrast medium in chronic pancreatitis.

Ionic and non-ionic contrast media used for contrast-enhanced computed tomography in experimental pancreatitis.

Contrast enhancement of the pancreas was studied in pigs using dynamic computed tomography in experimental oedematous and haemorrhagic/necrotizing pancreatitis during the first two minutes after injection of an intravenous bolus of non-ionic contrast medium (iohexol). The prospects of separating the two forms of the disease, known to be possible with ionic contrast media, were tested with a non-ionic contrast medium. In the oedematous form, contrast enhancement after 5 hours of the disease was significantly higher than in the haemorrhagic/necrotizing form. Contrast enhancement after 30 hours of disease tended to vary with the severity of the disease, showing that the course of oedematous pancreatitis is dynamic. Intermediate forms occur and follow-up studies are needed during the disease. A non-ionic contrast medium proved as good for separating the two forms of the disease in the early phase as were ionic contrast media. In severely ill patients, non-ionic contrast media should therefore be used.

Effect of pancreatitis on the absorption of contrast medium from the pancreatic duct.

The absorption of contrast medium (CM) from the pancreatic duct into blood and lymph was studied in piglets with oedematous (n = 5), haemorrhagic (n = 6) and chronic (n = 7) pancreatitis. Six healthy animals served as controls. In piglets with oedematous pancreatitis, lymphatic absorption was found to be delayed, whereas venous absorption remained almost normal. Haemorrhagic pancreatitis severely delayed both venous and lymphatic absorption, due to microvascular damage. CM absorption was also delayed in chronic pancreatitis. Absorption from the pancreatic interstitium was rapid in healthy and oedematously inflamed pancreas. The slow absorption during haemorrhagic pancreatitis means that the parenchyma is exposed to the effects of CM for a longer period.

Esophago-pericardial fistula. A case report and review of the literature.

A case of esophago-pericardial fistula is described which was treated successfully by pericardial drainage and closure of the fistula 12 days after perforation. The condition is rare and often fatal. In 29 reported cases there were only 5 survivors. On the basis of our observation and a review of the literature it is concluded that the first step in the treatment should be pericardial drainage and antibiotic coverage, followed by elective operative closure of the fistula.