Beyond visualizing the bird beak: esophagram, timed barium esophagram and manometry in achalasia and its 3 subtypes.

Achalasia is a rare esophageal motility disorder characterized by lack of primary peristalsis and a poorly relaxing lower esophageal sphincter. This disease process can be examined several ways and these evaluations can offer complementary information. There are three manometric subtypes of achalasia, with differing appearances on esophagram. Differentiating them is clinically important, because treatment for the subtypes varies. Timed barium esophagram (TBE) is a simple test to quantitatively evaluate esophageal emptying. TBE can be used to diagnose achalasia and assess treatment response. Considerable variation in the TBE protocol exist in the literature. We propose a standardized approach for TBE to allow for comparison across institutions.

Successful Non-Operative Management of Adhesive Small Bowel Obstruction: Is it Really a Success?

BACKGROUND: In adhesive small bowel obstructions (ASBOs), literature has shown that passage of a water-soluble contrast challenge at either 8 hours or 24 hours is predictive of successful non-operative management (NOM) for an ASBO, but the long-term outcomes between these two groups are unknown. We hypothesized that patients who require longer transit times to the colon have a higher one-year recidivism of ASBO. METHODS: This was a 4-year review of patients with presumed ASBO undergoing successful NOM. Those requiring operation or those with an SBO due to something other than adhesions were excluded. Patients were divided into two groups (8 hour and 24 hour) based on when contrast reached their right colon. Patients were followed for one year to determine ASBO recurrence. RESULTS: 137 patients underwent NOM; 112 in the 8-hour group and 25 in the 24-hour group. One-year recurrence rate was 21.4% in the 8-hour group and 40% in the 24-hour group (P = 0.05). The median time to recurrence was 113 days in the 8-hour group and 13 days in the 24-hour group (P = 0.02). Of those who recurred in the 24-hour group, 60% recurred within 30 days (P = 0.01). On univariable analysis, first-time ASBO and 24-hour transit time were risk factors for recurrence. CONCLUSIONS: Adhesive small bowel obstruction patients undergoing NOM in the 24-hour group had a recurrence rate nearly twice that of patients in the 8-hour group and may benefit from an operative exploration during the index hospitalization at the 8-hour mark of a water-soluble contrast challenge, especially if experiencing a first-time ASBO.

CT Attenuation of Acute Subdural Hematomas in Patients with Anemia.

BACKGROUND AND PURPOSE: Isodense and hypodense acute subdural hematomas have been reported in the literature in anemic patients. The purpose of this study is to see if there is a statistically significant difference between the Hounsfield unit measurements of acute subdural hematomas in anemic and nonanemic patients. METHODS: A total of 109 patients were analyzed. We measured the most hyperdense component of the subdural hematoma and compared these measurements for both anemic and nonanemic patients. RESULTS: All patients with anemia had a hyperdense component to their subdural hematomas during the acute period. No statistically significant difference was found in the density of the subdural hematomas between the two groups. More heterogeneous subdural hematomas were found in the anemic group than the nonanemic group, which suggests that anemia alone is not a sufficient explanation for acute homogenous isodense and hypodense subdural hematomas. CONCLUSION: A hyperdense subdural component was present in all acute subdural hematomas in anemic patients. Therefore, anemia alone is not a sufficient explanation for a homogenous low-density acute subdural hematoma.

Porcelain Gallbladder: Is Observation a Safe Option in Select Populations?

BACKGROUND: Management of gallbladder wall calcifications has been controversial for many decades. Although the traditionally perceived strong association with gallbladder cancer mandated prophylactic cholecystectomy, newer evidence suggests a much lesser association and might indicate an observational approach. STUDY DESIGN: A retrospective cohort study of 113 patients with gallbladder wall calcifications diagnosed between 2004 and 2016 at a single institution was conducted. Radiographic re-review identified patients with definitive (n = 70) and highly probable (n = 43) gallbladder wall calcifications. Patients were categorized according to their designated treatment plan. RESULTS: In the observation group (n = 90), delayed cholecystectomy for gallbladder-related symptoms was necessary in 4 patients (4%). None of the patients in this group were diagnosed with a gallbladder malignancy during a mean of 3.2 ± 3.2 years follow-up. In the operative group (n = 23), peri-operative complications occurred in 13%, and gallbladder malignancy was found in 2 patients. In comparison, although patients in the observation group were older and had more comorbidities, the rate of adverse events was not significantly different (4% vs 13%; p = 0.15) with an overall low risk for potentially life-threatening complications to the patient when observed clinically. CONCLUSIONS: For management of gallbladder wall calcifications, observation appears to provide no significant difference in adverse events, including the risk of gallbladder malignancy developing, compared with an operative approach. Although there is a need for intervention in the presence of symptoms and findings suggestive of malignancy, prophylactic cholecystectomy should be avoided in patients with limited life expectancy and significant comorbidities.

Diffusion-tensor imaging derived metrics of the corpus callosum in children with neurofibromatosis type I.

OBJECTIVE: MR morphometric studies have suggested that structural brain abnormalities including corpus callosum enlargement may, in part, explain cognitive deficits in children with neurofibromatosis type 1 (NF-1). Diffusion tensor imaging (DTI) metrics of the corpus callosum in adults with NF-1 have recently been reported, but such studies in children with NF-1 are needed. The purpose of this study was to quantify the DTI metrics at 3 T of different regions of the corpus callosum in children with NF-1. SUBJECTS AND METHODS: DTI metrics from seven consecutively identified patients with NF-1 (6 boys and 1 girl; age range, 3-17 years; average age, 7.0 years) were compared with 11 age- and sex-matched control subjects (10 boys and one girl; age range, 3-17 years; average age, 7.1 years) at 3 T. Fractional anisotropy, mean diffusivity, axial diffusivity, and radial diffusivity were calculated in different sections of the corpus callosum as well as whole-brain mean diffusivity. RESULTS: Comparing children with NF-1 to control subjects, there were statistically significant decreases in fractional anisotropy in the genu, anterior body, and isthmus of the corpus callosum and significant increases in radial diffusivity in the genu and anterior body. Whole-brain mean diffusivity histograms revealed significant increases in whole-brain mean diffusivity in children with NF-1. CONCLUSION: Children with NF-1 have abnormal DTI metrics, particularly in the genu, and elevated whole-brain mean diffusivity. NF-1-related microstructural abnormalities of the corpus callosum are detectable in childhood and likely persist through myelination maturation.