Endoscopic treatment of biliary disorders in patients with Roux-en-Y hepaticojejunostomy via a permanent access loop.

The management of biliary disorders in patients with Roux-en-Y hepaticojejunostomy anastomosis is challenging and remains controversial. Our aim is to share our experiences of endoscopic treatment via a permanent access loop in 5 patients. Endoscopic treatment via a permanent access loop is an invaluable procedure for the management of stenotic hepaticojejunostomy anastomosis, anastomotic leakage, and hepatolithiasis. It may even be life-saving for some patients.

Left cervical aortic arch in conjunction with a complex arch aneurysm and subaortic left innominate vein.

We present a patient with left cervical aortic arch who had a complex aortic arch aneurysm consisting of multiple saccular aneurysmatic excavations, proximal aortic arch narrowing, a right subclavian artery aneurysm and subaortic left innominate vein diagnosed by computed tomographic angiography.

Clinical value of 16-slice multidetector computed tomography in symptomatic patients with suspected coronary artery disease.

BACKGROUND: Multidetector computed tomography angiography has emerged as a rapidly developing method for the noninvasive detection of coronary artery disease. PURPOSE: To investigate the diagnostic accuracy and limitations of multidetector computed tomography (MDCT) in the detection of significantly (> 50%) obstructive coronary artery disease (CAD) using a scanner equipped with 16 x 0.625-mm collimation. MATERIAL AND METHODS: MDCT angiography was performed in 153 patients (99 male, 54 female; mean age 55 +/- 10 years) with suspected CAD and scheduled for conventional coronary angiography (CCA). Image quality was assessed in terms of artifacts and segment visibility, and the assessable segments were screened for the presence of significant stenoses (> 50% lumen diameter reduction). The diagnostic performance of MDCT for the detection of significant stenosis was compared with the results of CCA. RESULTS: In all 153 patients, MDCT was carried out without complications. A total of 1989 coronary artery segments were evaluated. After exclusion of 394 non-evaluable segments (19.8%), 1595 segments (80.2%) were included in the analysis. The most frequent causes of poorly assessable segments were motion artifact (36%) and severe calcification (23%). Considering only the segments judged to be evaluable, the sensitivity, specificity, and positive and negative predictive values of 16-slice MDCT were 85%, 97%, 79%, and 98%, respectively. Including all segments in the analysis (evaluable and non-evaluable), the sensitivity was 74%, specificity 96%, positive predictive value 73%, and negative predictive value 97%. CONCLUSION: When all coronary artery segments are included, 16-slice MDCT has moderate sensitivity and very high specificity and negative predictive value in assessing coronary artery stenoses. High specificity and negative predictive value indicate that 16-slice MDCT may be a useful tool in reliably ruling out significant lesions in patients with a low pretest probability.

Correlation of right atrial pressure and blood flow velocities in the common femoral vein obtained by duplex Doppler sonography.

PURPOSE: The purpose of this study was to correlate the right atrial pressure with the blood flow velocity and pulsatility index (PI) values obtained with duplex Doppler sonography of the common femoral vein. METHODS: Thirty consecutive patients with suspected right-sided heart failure who had right atrial pressure measurements for correlation were included in the study. The common femoral veins were examined with duplex Doppler sonography. Irrespective of the presence or absence of clinical right-sided heart failure, patients were divided into 2 groups on the basis of their right atrial pressures. The mean flow velocities and PIs in the common femoral veins of the 2 groups were compared. RESULTS: In patients with elevated right atrial pressure (> or = 8 mm Hg), the mean minimum flow velocity + standard deviation (-0.15 +/- 0.11 m/second) in the common femoral vein was significantly lower than that in patients with normal right atrial pressure (< 8 mm Hg) (0.01 +/- 0.10 m/second) (p < 0.001). There was no significant difference in the mean maximum flow velocities in the common femoral vein between the patients with elevated right atrial pressure (0.25 +/- 0.08 m/second) and the patients with normal right atrial pressure (0.21 +/- 0.09 m/second). The mean PI in patients with elevated right atrial pressure (7.75 +/- 3.19) was significantly higher than the mean PI in patients with normal right atrial pressure (1.55 +/- 1.30; p < 0.001). There was a weak negative correlation between the minimum flow velocity and the pressure in the right atrium in patients with elevated right atrial pressure (p = 0.05; r = -0.4760). The amplitude of retrograde waves seen in patients with normal right atrial pressure was significantly smaller than in patients with elevated right atrial pressure (p < 0.05). CONCLUSIONS: The association of a decreased minimum velocity, especially a negative value, and an increase in PI in the common femoral vein may indicate an elevated right atrial pressure. Sonographic assessment of retrograde flow velocity in the common femoral vein may be useful in monitoring the response to medical treatment to decrease atrial pressure.

Postpartum follow-up of hepatic calcification detected by prenatal ultrasound.

The causes of parenchymal hepatic calcification are mostly transplacental infection of TORCH complex, ischaemic necrosis, or tumours of foetal liver including haemangioma, hamartoma, teratoma, hepatoma, and hemangioendothelioma. Vascular pathologies like hepatic artery aneurysm, haematoma, calcified thromboemboli of portal vein and hepatic veins can also cause hepatic calcification. We present a case of hepatic calcification which was first diagnosed by prenatal ultrasound. In the postpartum follow-up, we observed that the calcifications had decreased in number and size. The causes and results of hepatic calcification or underlying disease are discussed with analysis of the literature.

Presinusoidal portal hypertension does not affect hepatic artery resistance index.

We aimed to determine the mean hepatic artery resistance index (RI) in presinusoidal portal hypertension and to compare the values with those in sinusoidal portal hypertension. The hepatic artery RIs of 11 patients with presinusoidal portal hypertension, 12 patients with sinusoidal portal hypertension and 16 healthy subjects were examined with duplex Doppler ultrasound. Mean hepatic artery RIs of three groups were compared. In patients with presinusoidal portal hypertension, mean RI in the hepatic artery (0.63 +/- 0.06) was significantly lower (p < 0.05) than that in the patients with sinusoidal portal hypertension (0.73 +/- 0.03). There was no significant difference (p > 0.05) in the mean RIs of the hepatic artery between the patients with presinusoidal portal hypertension (0.63 +/- 0.06) and the controls (0.67 +/- 0.05). Mean RI value in patients with sinusoidal portal hypertension (0.73 +/- 0.03) was significantly higher (p < 0.05) than the mean values in the control group (0.67 +/- 0.05). Hepatic arterial resistance does not change in presinusoidal portal hypertension, whereas it increases in sinusoidal portal hypertension. However, there are some overlaps in the RI values which raise difficulties in the differentiation of these two forms of portal hypertension.

Pseudoaneurysm of the abdominal aorta diagnosed by color duplex Doppler sonography.

A pseudoaneurysm of the abdominal aorta is rare, accounting for only 1% of all abdominal aneurysms. More than 1 imaging method may be needed to demonstrate an abdominal aortic pseudoaneurysm. We report a case in which the presence of continuous bidirectional flow in the neck of a pseudoaneurysm on color duplex Doppler sonography confirmed the diagnosis.

Superior mesenteric artery blood flow in patients with small bowel diseases: evaluation with duplex Doppler sonography.

PURPOSE: This study was conducted to determine how the hemodynamic parameters of the superior mesenteric artery are affected in small bowel diseases. METHODS: One hundred thirty-seven patients whose clinical symptoms suggested an intestinal abnormality were evaluated with duplex Doppler sonography. The control group comprised 42 subjects recruited from the medical staff or from patients referred for renal sonography. RESULTS: In 38 patients with diverse small bowel diseases, mean blood flow volume to the superior mesenteric artery territory (1.115+/-0.470 l/min) was significantly greater (p < 0.01) and the mean resistance index (0.82+/-0.06) was significantly lower (p < 0.05) than the mean values in the control group (0.692+/-0.250 l/min and 0.85+/-0.04, respectively). The mean peak systolic velocity and end-diastolic velocity in bowel disease patients were higher than the mean values in the control group. CONCLUSIONS: Various intestinal abnormalities share common Doppler findings, eg, increase in blood flow volume, increase in both peak systolic and end-diastolic velocities, and decrease in resistance index. However, the absence of these findings does not exclude the possibility of small intestinal disease because of the overlap of the measurements in diseased and healthy subjects.

Superior mesenteric artery Doppler waveform changes in response to inflammation of the ileocecal region.

In the present study, we determined how Doppler waveforms of the superior mesenteric artery (SMA) are affected by inflammatory processes in the ileocecal region. Twenty-two patients (aged 20-69 years) with ileocecal region inflammation (ICRI) were examined with duplex Doppler Ultrasonography to establish whether any significant changes were present in the mean blood flow parameters of peak systolic velocity (PSV), end-diastolic velocity (EDV), resistive index, pulsatility index, blood flow volume, and diameter of the SMA. The findings were compared with those of 22 volunteer controls. Mean blood flow volume in the SMA in patients with ICRI (1.128 +/- 0. 43 L/min) was significantly greater (p < 0.001) than that in the control group (0.643 +/- 0.19 L/min). The mean PSV (1.87 +/- 0.44 m/s) and the mean EDV (0.31 +/- 0.18 m/s) were also significantly (p < 0.01) higher than those of the means in healthy subjects (mean PSV = 1.44 +/- 0.26 m/s and mean EDV = 0.20 +/- 0.05 m/s). ICRI, regardless of cause, increases both the flow velocities in the SMA and the flow volume to the SMA territory.

Hepatic vein Doppler waveform changes in early stage (Child-Pugh A) chronic parenchymal liver disease.

Doppler waveform changes can be found in chronic parenchymal liver disease, especially in the late stages. We investigated the contribution of Doppler ultrasound in diagnosing early-stage chronic parenchymal liver disease. In this prospective study, 30 patients who had been diagnosed with chronic liver disease (Child-Pugh class A) and 30 healthy subjects were studied. The diagnosis was confirmed with histopathologic examinations of biopsy specimens in 17 patients. The Doppler US examination of hepatic veins was performed in all the patients and healthy subjects. The Doppler US pattern was classified into three groups according to the Doppler signal characteristics: (1) type 0, triphasic waveform, the presence of a short phase of reversed flow, (2) type I, decreased amplitude of the phasic oscillations without the short phase of reversed flow, and (3) type II, complete flat waveform. Normal hepatic vein waveforms (type 0) were found in 8 patients (26.66%) and abnormal hepatic waveforms (type I + type II) in 22 patients (73.33%). The results of Doppler ultrasonography were correlated with the diagnosis of early-stage chronic parenchymal liver disease (Child-Pugh class A). In all the subjects of the control group, the Doppler waveform of hepatic veins showed the triphasic pattern (type 0). In the statistical evaluation using Fisher's exact test we observed that there was a significant difference (p < 0.05) between the control group and the patient group with respect to the presence of abnormal (type I + type II) Doppler waveform. The diagnostic accuracy in the patients who had biopsy was 76.47% and that in the patients who did not was 69.23%.

Isthmus hypertrophy mimics tumour in horseshoe kidney: a case report.

We present a case of horseshoe kidney. He was operated because of nephrolithiasis, and was found to have a tumour-like mass in the isthmic localization 2 years after the operation. The tumour-like mass was proven to be an isthmus hypertrophy after detailed research.

Sonourethrography in anterior urethral stricture: comparison to radiographic urethrography.

Twenty-three male patients with known or suspected urethral stricture disease were evaluated using sonourethrography and standard retrograde x-ray urethrography for comparative analysis of two techniques. Results were evaluated statistically. These two methods can substitute each other in determining the stricture area length of anterior urethra. Due to advantages, if both of these methods are used combining each other, we believe that they will be much more sensitive.

Duodenal phytobezoar: a case report and review of the literature.

Phytobezoars are an unusual cause of small bowel obstruction. We report a case of small bowel obstruction due to phytobezoar in a 63 year-old female patient who had undergone gastric surgery (truncal vagotomy with pyloroplasty) for duodenal ulcer disease complicated by gastric outlet obstruction 10 years ago. We diagnosed this bezoar case by radiologic methods and these methods keep their importance for the diagnosis of small bowel obstruction with phytobezoars.

Agenesis of the celiac trunk: an angiographic case.

In the angiography performed for a clinical diagnosis, a unique case of "agenesis of the celiac trunk" was encountered in a 42-year-old Turkish male. There was instead an artery which arose from the aorta at the level of the first lumbar vertebra, and supplied blood to the territory of both the celiac and superior mesenteric arteries by giving rise to the splenic, the jejunal, the ileal, the pancreaticoduodenal, the proper hepatic and the left gastric arteries, consecutively.