Splanchnic venous obstruction. A complication of chronic pancreatitis.

A retrospective review of 20 adult patients with splanchnic venous obstruction secondary to chronic pancreatitis was performed to identify factors important in the preoperative diagnosis and operative management of this disorder. Fifteen patients with isolated splenic vein obstruction, four with portal occlusion and one with isolated inferior mesenteric vein occlusion were studied. Chronic alcoholism was the etiology of the pancreatitis in 18 patients; two patients had a Type IV hyperlipidemia. Four patients with massive hemorrhage from gastric varices were treated with splenectomy. Most patients presented with complaints of chronic pancreatitis, requiring pancreaticojejunostomy to treat the underlying pancreatic disorder. Splenic artery inflow control was obtained preoperatively in six patients and offers a technique that is beneficial in decreasing operative blood loss. The dynamic computerized tomography (CT) scan was a valuable diagnostic tool in identifying splanchnic venous obstruction although selective angiography is required for confirmation of the diagnosis.

Prediction of pneumothorax rate in percutaneous needle aspiration of the lung.

Pneumothorax (PTX) is the most common complication associated with percutaneous needle aspiration (PNA) of the lung. Age, sex, cooperation, and lesion size, location, and depth, as well as needle size, number of passes, and radiographic calculation of total lung capacity all have been implicated in influencing the rate of PTX. Pulmonary function testing to assess PTX risk in PNA has not been previously examined. We retrospectively reviewed 159 patients undergoing PNA who had preprocedure spirometry (PFT) and chest roentgenogram (CXR) interpreted for changes of obstruction or restriction to determine if these classifications could stratify patients at high risk for PTX. We also examined single variables to determine their predictive power. Patients with normal PFT and CXR had a 10 percent risk of PTX, and only one such patient needed intervention to treat the PTX. Obstruction by PFT, regardless of CXR findings, predicted a 50 percent PTX rate. Among single variables, FEV1 proved to be the most significant predictor of PTX. Preprocedure spirometric testing can enhance the assessment of PTX risk and should be routinely performed prior to needle aspiration.

Postbiopsy pneumothorax: estimating the risk by chest radiography and pulmonary function tests.

Pulmonary function tests and chest radiographs of 160 patients who had had percutaneous needle biopsy of lung lesions were reviewed to determine the value of these examinations in estimating the risk of postbiopsy pneumothorax. Chest radiographs were evaluated subjectively for changes of obstructive and restrictive airway disease and for size and depth of lesion. Pulmonary function tests, consisting of simple spirometry (forced vital capacity, percentage of predicted forced vital capacity, forced expiratory volume in 1 sec, percentage of predicted forced expiratory volume in 1 sec, and [forced expiratory in 1 sec/forced vital capacity] X 100), and the pulmonologist's interpretation were evaluated. Pneumothorax developed in 46% (31/67) of patients who had obstructive airway disease according to the results of pulmonary function tests and in 42% (34/81) of those who had obstructive airway disease according to changes on chest radiographs, compared with 19% (10/53) and 25% (17/67) of those who had normal pulmonary function tests and chest radiographs, respectively. Pneumothorax developed in 46% (23/50) of patients who had findings of obstructive airway disease on both pulmonary function tests and on chest radiographs, compared with 7% (2/28) of patients who were classified as normal by both criteria. None of the patients who had normal pulmonary function tests required placement of a chest tube, whereas 19% (13/67) of those who had obstructive airway disease required chest tubes. Decreasing size of lesion and increasing depth of lesion were associated with a significant increase in the risk of pneumothorax. We conclude that the results of chest radiographs and pulmonary function tests are useful parameters for estimating the risk of postbiopsy pneumothorax.

Percutaneous drainage of pancreatic and peripancreatic fluid collections.

Radiographically guided therapeutic percutaneous catheter drainage was used to manage 25 patients with 27 pancreatic and peripancreatic fluid collections. Nine of 11 (82%) noninfected and 11 of 16 (69%) infected collections were successfully managed with percutaneous drainage. Overall, eight complications and four deaths occurred in this group of patients. The morbidity and mortality in this series is somewhat higher than that previously reported in the radiologic literature. A discussion of the guidelines for percutaneous drainage is presented.

Lung lesions: cytologic diagnosis by fine-needle biopsy.

Small-bore (22- or 23-gauge) needles were used to aspirate 458 lung masses. Sensitivity for the detection of malignancy by this method was 96.6% (312 of 323 patients); accuracy was 98.7%. Surgical confirmation was available for comparison in over half of patients with malignancy. Histologic reclassification of malignancy occurred in only 6.1% of patients, with significant misclassification (misdiagnosis of small cell carcinoma) occurring in only two instances. One hundred thirteen of 117 nonmalignant conditions were properly categorized, with an overall specificity of 96.6%. No major complication occurred. While several recent studies have stressed the advantage of using larger needles, to overcome the limitation of smaller aspiration needles that provide only cytologic material, small-needle aspiration appears to be a safe, reliable, and accurate means for diagnosing lung lesions.

Thrombosed right renal vein varix simulating a renal pelvic mass.

A solitary thrombosed varix of the right renal vein was mistaken preoperatively for a renal tumor. Computed tomography, retrograde pyelography, arteriography, and needle biopsy did not establish the diagnosis. Renal venography would have confirmed the diagnosis of this extremely rare condition.

Failure to visualise the abdominal portion of the inferior vena cava with computed tomography: a clue to underlying abdominal pathology.

Failure to visualise the intra-abdominal portion of the inferior vena cava (IVC) using contrast-enhanced computed tomography (CT) is unusual. A review of 1272 contrast-enhanced abdominal CT examinations revealed that the IVC was not visible at one or more levels in only 132 (10.4%). In 57 (43%), non-visualisation was due to pathological processes, most frequently metastatic carcinoma, causing compression or thrombosis of the IVC. In the remainder, technical factors or artefacts could explain the non-visualisation. Techniques and procedures to improve visualisation of the IVC are discussed. Failure to visualise the IVC on CT at any level unexplained by artefacts is abnormal.

Sonographic findings in abdominal pregnancy.

The sonograms of 20 proven cases of abdominal pregnancy were evaluated to determine the frequency of specific abnormalities associated with this condition. The most frequent and reliable finding was separation of the uterus from the fetus (90%). Extrauterine placenta (75%) and oligohydramnios (45%) were next in frequency. Other features such as fetal parts close to the maternal abdominal wall (25%), failure to visualize myometrium between the fetus or placenta and maternal bladder (15%), abnormal fetal lie (25%), poor visualization of the placenta (25%), and maternal bowel gas impeding fetal visualization (25%) were noted.

Pseudoepidural reverberation artifact: a common ultrasound artifact in fetal cranium.

High-intensity reverberation artifacts frequently occur within the fetal cranium during obstetric ultrasound examinations. One hundred ninety-six static ultrasonograms obtained from 100 consecutive obstetric patients were reviewed to determine the incidence, shape, and location of high-intensity reverberation artifacts within the fetal head. Such artifacts occurred in one-third of the fetuses examined. The most common appearance was an arc-shaped artifact that occurred most frequently in the fetal hemicranium farthest from the maternal skin surface. Such an artifact can mimic epidural fluid collections and cause confusion for examiners not familiar with this finding. A discussion of this "pseudoepidural" artifact, its cause, and ways of excluding underlying intracranial pathology is presented.

Pancreaticopleural fistula: demonstration by computed tomography and endoscopic retrograde cholangiopancreatography.

Pancreaticopleural fistula is an uncommon complication of chronic pancreatitis or pancreatic trauma. Clinical features include pleural effusion and resulting pulmonary symptoms. Abdominal pain and other clinical manifestations of pancreatitis may be minimal or absent. As in this case, computed tomography and endoscopic retrograde cholangiopancreatography may provide complementary diagnostic information in the evaluation of this condition. A discussion of the pathophysiology, diagnosis, and management of pancreaticopleural fistula is presented.

Exogastric leiomyoblastoma: a rare gastric neoplasm mimicking left hepatic mass on computed tomography.

Leiomyoblastomas are rare gastric neoplasms that may occur as exogastric masses, producing difficulty in correct localization and diagnosis. Two exogastric leiomyoblastomas were misdiagnosed as primary hepatic lesions due to their appearance on computed tomography. A discussion of these rare neoplasms, the potential for their erroneous diagnosis, and ways to avoid this computed tomography pitfall is presented.

Embolic management of rare hemorrhagic gynecologic and obstetrical conditions.

Severe life-threatening hemorrhage was controlled by angiographic management in 3 patients with bleeding due to unusual gynecological abnormalities and in 1 patient with a rare obstetrically related hemorrhage. Successful management of such rare causes of bleeding emphasizes that early angiographic intervention can, in selected patients, reduce the need for an immediate or subsequent surgical procedure and allow conservative management followed by disease-specific therapy.

Quantitative analysis of the cervical spinal canal by computed tomography.

Computed tomography measurements of the AP diameter, width, and cross-sectional area of the bony cervical canal were derived from cervical spine examinations of fifty-two normal adults. These quantitative parameters were then used to evaluate 80 patients with various cervical abnormalities to determine the clinical usefulness of the measurements. With the exception of spinal stenosis, quantitative cervical canal analysis was found to be of limited usefulness since normal measurements frequently occurred in the presence of significant cervical pathology.

The current status of breast imaging.

The use of the various methods available for breast imaging are described and recommendations are made for the appropriate use of the different modalities. When applicable, benefits versus risks are considered. The currently recommended schedule for mammographic screening is presented. The technique for localizing nonpalpable suspicious lesions detected during screening mammography is discussed.

Computed tomography evaluation of pheochromocytoma in pregnancy.

Two cases representative of the spectrum of the problem of pheochromocytoma in pregnancy are presented. One patient was typical of many cases of pheochromocytoma not diagnosed until delivery, with resultant maternal and fetal death. Computed tomography accurately preoperatively localized a pheochromocytoma involving the organ of Zuckerkandl in the second patient, with subsequent uncomplicated removal of the tumor during a cesarean delivery. A discussion of pheochromocytomas in pregnancy and the relative risk and benefits of preoperative localization with computed tomography are presented.

The effect of drainage tube size on adequacy of percutaneous abscess drainage.

Fifty-one patients with documented abdominal abscess cavities were treated by percutaneous abscess and fluid drainage (PAFD). Drainage catheters made of various materials in sizes ranging from 5 through 18 French (Fr) were retrospectively studied and prospectively assigned to patients. No significant difference in the success or failure of PAFD as a function of these factors was found once an 8.3 Fr catheter with 0.045-inch diameter side-holes was reached; catheters larger than this were not associated with improved patient outcome. Failues of PAFD occurred primarily with the presence of phlegmonous collections and cavities with fistulous connection to bowel.

Interstitial lung disease in scleroderma. Analysis by bronchoalveolar lavage.

Interstitial pulmonary fibrosis is a common feature of scleroderma (systemic sclerosis) which may result in impairment of pulmonary function and may be a major determinant of morbidity and mortality. Clinicopathologic observations suggest that interstitial and alveolar inflammation may appear prior to fibrosis. Using the bronchoalveolar lavage (BAL) technique, we have characterized the nature of the inflammatory process in the lower respiratory tracts of 19 non-smoking scleroderma patients. Eleven of 19 patients (58%) had increased percentages of neutrophils and/or eosinophils in BAL fluid. Five of 10 patients (50%) had elevations of IgG in BAL fluid. The presence of neutrophils was associated with a decreased lung diffusing capacity for carbon monoxide (P less than 0.05) and with more advanced radiographic features of interstitial fibrosis in patients with disease of more than 1 year's duration. This study suggests that scleroderma lung involvement may be characterized by an inflammatory alveolitis and that the presence of such inflammation may relate to the severity of the pulmonary disease.

Computed tomography as an angiographic aid in evaluation of intraabdominal hemorrhage.

The role of computed tomography in the evaluation of patients with intraabdominal hemorrhage in the absence of trauma history has received little attention. Representative cases are presented demonstrating how preangiographic, postangiographic, and combined computed tomography-angiography can aid in the diagnosis and localization of obscure causes of intraabdominal and gastrointestinal bleeding.