Massive upper gastrointestinal hemorrhage with normal findings on arteriography: value of prophylactic embolization of the left gastric artery.

During a 5-year period, 13 patients who presented with massive upper gastrointestinal hemorrhage had normal findings on arteriography. Seven had prophylactic embolization of the left gastric artery, and six had conservative therapy. Normal angiographic findings were associated with clinical cessation of bleeding in 12 of 13 patients. Lesions not treated by embolization or other invasive therapy had a high rate of massive recurrent hemorrhage (four of six). Of lesions subsequently found to be supplied by the left gastric artery, two of four cases not treated by embolization or surgery had clinically significant recurrent hemorrhage, whereas none of six cases treated by embolization had recurrent hemorrhage. Prophylactic embolization of the left gastric artery appears warranted when (1) there is definite prior identification of a lesion in the left gastric artery territory or (2) there is no prior localization of a lesion but the patient is at risk for multiorgan failure if bleeding recurs.

Functional abnormalities of the gastrointestinal tract in patients with spinal cord injuries: evaluation with imaging procedures.

One quarter of patients with spinal cord injuries eventually have severe chronic gastrointestinal symptoms. Because there are about 1.5 million such patients in the United States, major chronic gastrointestinal symptoms will develop in approximately 400,000 patients, all of whom are likely to need the services of radiologists. These gastrointestinal abnormalities, however, are quite different from the gastrointestinal problems that occur in the general population. For this reason, the imaging methods used for diagnosis in these patients are also different from those used with persons who do not have spinal cord injuries. The purpose of this review is to describe the role of diagnostic imaging in patients with severe chronic gastrointestinal symptoms associated with spinal cord injury.

Congenital anomalies of the inferior vena cava: embryogenesis and MR features.

This article describes the MR appearances of the six most common congenital anomalies of the inferior vena cava. As a basis for understanding those anomalies, it describes the embryology of the inferior vena cava, based on an actual study of embryos and fetuses. The article takes a fresh look at the original research in this area, discusses the possible embryogenesis of the relevant anomalies, and describes different opinions on that subject, where different opinions exist.

The role of imaging in prostate cancer.

For patients with prostate cancer, diagnostic imaging can play three roles: screening, staging, and monitoring. Bayesian analysis dictates that if the prior probability of cancer is relatively low or if the consequences of a false-positive result are unacceptable, the test must be optimally specific. If the prior probability of cancer is high or if the consequences of missing it are unacceptable, the test must be optimally sensitive. For screening, the consequences of a miss are slight, and the consequences of labeling an insignificant cancer significant are serious. Thus, a very specific test is required. No current imaging modality fulfills this criterion. For staging, the prior probability of significant disease is relatively high, and the consequences of a miss serious, so a very sensitive test is required. Transrectal sonography, plus biopsy under sonographic control, fulfills this criterion for local disease, as does a bone scan for bone metastases. For monitoring, the prior probability is high, and the consequences of a miss serious, so a very sensitive test is needed. The bone scan is sensitive for bone metastases. Although CT is not sensitive for detecting lymph node metastases, it has practical clinical advantages over other imaging modalities for monitoring purposes in that it can detect disease in multiple structures at once. It is the only test that can monitor prostate size, the size of the lymph nodes, and whether hydronephrosis or liver metastases are present all in the scope of one examination.

The role of imaging in screening for prostate cancer. A decision analysis perspective.

Using Bayesian and decision analytical concepts, we can define the ideal characteristics of any screening test for cancer of the prostate: high specificity, reasonably high sensitivity, noninvasiveness, low cost, and low interobserver variability. Computed tomography (CT) fails as a test, since it cannot show the internal structure of the prostate; MRI is too expensive and has an unacceptably poor specificity. Transrectal sonography does have many desirable characteristics, including relatively high sensitivity and, if no biopsy is done, low cost and noninvasiveness. But it has an unacceptably low specificity for early, clinically significant lesions: over half of all patients tested will have a positive result, requiring a confirming biopsy, which means that transrectal sonography will in the end be too invasive and too expensive. Therefore, we cannot recommend transrectal sonography as a primary screening tool for cancer of the prostate at this time.

Written informed consent for i.v. contrast-enhanced radiography: patients' attitudes and common limitations.

In a multiinstitutional study, we surveyed 902 patients who were undergoing IV contrast-enhanced CT or IV urography; the purpose of the study was to determine patients' reactions to being given a written description of some of the risks associated with radiographic contrast material just before undergoing the examination. Ninety percent of the patients who responded said they would rather receive this information than not receive it. Ten percent said they preferred not to be given the information. Limitations in obtaining a truly informed consent were not rare and occurred in patients with medical emergencies (3% of cases) and in those with a limited understanding of risk disclosure (11% of cases). Patients in the latter category included those who were comatose or semicomatose (2%), those with dementia (1%), those with aphasia (0.8%), those who had psychiatric problems (0.8%), those who were sedated (0.6%), those who were unable to read (2%), those who were unable to understand English (2%), and those who perceived the information as too technical (0.9%). Two percent of the patients were minors. Our survey shows that practical limitations in obtaining adequate risk disclosure are common, but most patients want and accept information about the risks of having IV contrast-enhanced CT or IV urography before undergoing the procedure.

Duplicated urethra communicating with the seminal vesicle.

This article describes the first case of a duplicated urethra in which the accessory urethra drained the seminal vesicle, and suggests a possible embryologic basis for the anomaly.

Imaging the effects of an ectopic spleen on the urinary tract.

A 75-year-old woman with chronic lymphocytic leukemia who presented clinically with urinary frequency was found on physical examination to have a pelvic mass. Ultrasound and computed tomography showed it to be due to a large ectopic spleen lying in the pelvis behind the bladder and compressing it anteriorly. The spleen became smaller and the symptoms regressed with chemotherapy. We review the features of an ectopic spleen as seen on diagnostic imaging studies.

Bladder infarct.

We present here a case of a bladder infarct as a complication of aortofemoral bypass surgery. An intravenous urogram 6 weeks after surgery showed reduced expansion on the left side of the bladder and a sausage-shaped filling defect at the site of the infarct. The diagnosis was made by histologic examination of bladder wall biopsies.

Unusual fistulae between the rectum and the lower urinary tract: simple techniques for diagnosis.

This paper presents two unusual fistulae between the rectum and the lower urinary tract in adults, one a posttraumatic fistula following dilatation of a sigmoid colon stricture and the other a congenital anomaly. In both cases a contrast enema was negative; in one case a voiding cystourethrogram was negative. The fistula was demonstrated in case 1 by repeating the enema and having the patient raise his intraabdominal pressure, and in case 2 by having the patient hold while attempting to pass flatus during a cystogram, which demonstrated gas bubbles entering the bladder.

Obliterative pyelitis.

A patient with severe undiagnosed and untreated pyelitis developed mural masses in the renal pelvis and in the infundibulum of the upper pole calyx. The masses were presumed to be inflammatory. The patient developed a severe stricture of the renal pelvis and complete occlusion of the upper pole calyx. This is an example of obliterative pyelitis, as described in the era before antibiotics were available.

Staging of genitourinary cancers. The role of diagnostic imaging.

Computed tomography (CT) is currently the standard modality for staging of urologic cancer in most institutions. It is used for demonstrating nodal involvement, and for demonstrating invasion of the primary lesion into surrounding fat, muscle, or other tissues or organs. It is also useful for demonstrating hepatic metastases in renal and vesical carcinomas. The problem with computed tomography, however, is that it can only show whether the nodes are large or not; neither can it show the nodal architecture, nor can it detect metastases in normal-sized nodes. Intravesical sonography has been helpful for staging papillary bladder cancer. Transrectal sonography has been somewhat helpful for demonstrating seminal vesicle invasion in patients with prostatic carcinoma. Inferior vena cavography and renal venography can be helpful for demonstrating whether a renal, renal pelvic, or adrenal carcinoma has extended into either vein. Lymphography can show nodal architecture and metastases in normal-sized nodes, and can make possible needle biopsy of abnormal-appearing nodes even if they are normal sized. The examination cannot show very small or microscopic nodal metastases, and it can miss abnormal nodes totally if they have been completely replaced by metastases. It yields false positives when fatty or fibrous infiltration of the nodes has occurred. It is used primarily for staging patients with testis or prostatic carcinoma. Bone scans are essential for staging prostatic carcinoma. Magnetic resonance imaging (MRI) is helpful in some cases of renal cell carcinoma. Multiplanar imaging prevents overstaging. It is also accurate for showing whether the renal vein or inferior vena cava are involved. Enlarged lymph nodes are easily distinguished from vessels. For staging bladder carcinoma involving the fundus or base of the bladder, MRI is better than CT. Microscopic nodal metastases, such as are common in carcinoma of the prostate, currently are not detected by any imaging modality.

Ultrasonographic detection of false passages arising from the posterior urethra in spinal cord injury patients.

We report on false passages arising from the posterior urethra in 10 male spinal cord injury patients, of which 9 were well visualized on transrectal sonography, with real-time linear array equipment that was used to monitor a urodynamics catheter being introduced into the prostatic urethra. The only false passage not detected was at the bladder neck. Nevertheless the data show that transrectal sonography is an excellent tool to demonstrate false passages arising from the prostatic urethra. All 10 false passages were unroofed successfully with excellent results.