Traumatic pseudocyst of the spleen.

Four patients with pseudocyst of the spleen gave histories of abdominal trauma. In one patient the pseudocyst had ruptured, necessitating emergency splenectomy 34 years after the original injury. In a second patient the pseudocyst was discovered incidentally, and was managed by spleen-preserving excision; and the third and fourth presented with abdominal pain and had splenectomy and spleen-preserving surgery, respectively. All patients with conservatively treated splenic injury are at risk of developing a pseudocyst of the spleen, and the lesion can be detected by computed tomography or ultrasound. When there are no symptoms the natural history is unknown; but if surgery is necessary, splenectomy can sometimes be avoided.

Abdominal tuberculosis.

Throughout the world tuberculosis is associated with poverty, deprivation, and human immunodeficiency virus infection. Abdominal tuberculosis is usually of insidious onset with diverse symptoms and signs. A few present with acute complications of perforation, obstruction, or bleeding. The diagnosis is difficult, especially in areas where the disease is less common, as many patients do not have evidence of pulmonary tuberculosis or a positive skin test. The main differential diagnosis ranges from Crohn's disease in the young and advanced malignancy in the elderly. Delayed diagnosis is common, resulting in high mortality. Many investigations provide findings suggestive but not diagnostic of tuberculosis. With peritoneal tuberculosis, assay of ascitic fluid adenosine deaminase activity is a valuable, simple method of diagnosis that may reduce the need for laparoscopic biopsy. If the clinical suspicion of abdominal tuberculosis is high, a trial of medical treatment is appropriate. Surgery should be reserved for the complications of the disease. All patients require treatment with three antituberculous drugs over a 6-month course.

The distribution of atherosclerosis in the lower limbs.

Sixty-seven consecutive aortograms in non-diabetic patients were studied to establish the distribution of atherosclerosis in the arteries of 134 lower limbs. Prolonged filming and multiple exposures of the feet showed ankle vessels in 131 of the limbs (98%) and a pedal arch or collaterals in 126 (93%). In 51% of the limbs at least one of the calf arteries was occluded and only 24% had two patent arteries at ankle level. The pedal arch was complete in only 16%. The patency rate of the pedal arch was similar in all three symptom groups (p greater than 0.05). Two separate analyses were performed. The first was based on symptoms. Critical ischaemia was present in 18 limbs (13%), claudication in 69 limbs (52%) and 47 limbs were symptomless (35%). The second analysis was based on the sites of major occlusion. Occlusions were already present in 81% of the symptomless limbs, predominantly in the distal vessels. In limbs with claudication or critical ischaemia there were more occlusions above the knee (77 and 89%, respectively) than in limbs without symptoms (36%) (chi 2 = 27.60, p less than 0.001). Occlusion of the popliteal artery was significantly more frequent in the patients with symptoms of critical ischaemia (50%) than in either of the other two groups (chi 2 = 15.61, p less than 0.001). Atherosclerosis appears to develop in the small vessels of the calf and foot at an early stage. The extent of this involvement may influence the progression of symptoms and the outcome of treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

Duodenal ulcer hemorrhage in the puerperium.

Hemorrhage from a peptic ulcer during pregnancy is a rare complication that occurs most frequently near term or in the puerperium. A case of massive hematemesis from a duodenal ulcer on the third puerperal day is described. Emergency surgery with vagotomy and pyloroplasty was performed. The mother had no symptoms of peptic ulceration until the onset of mild abdominal pain 4 days before delivery.

A modified technique of pre-operative aortography to demonstrate the complete arterial tree of the lower limb.

One hundred consecutive aortograms were studied to establish the efficacy of conventional arteriography in demonstrating distal vessels and the pedal arch. The standard technique was modified by using a long injection time, a large volume of contrast material (iopamidol 370), prolonged filming and multiple exposures of the feet. On the basis of these examinations each limb was classified as having aorto-iliac disease (18 limbs), superficial femoral disease (103 limbs), combined segment disease (28 limbs) or generalised disease (51 limbs). Calf and ankle arteries were seen in 196 of the 200 limbs (98%). Patency of the pedal arch was established in 184 (92%). Fourteen percent of the group of patients with combined segment disease did not have their pedal arch visualised and this group contained most of the examination failures. This modified method of aortography can demonstrate the entire arterial tree from the aorta to the foot in 92% of limbs with symptomatic chronic atherosclerotic disease. This allows the majority of peripheral vascular reconstructions to be planned and performed without the need for intra-operative arteriography.

Abdominal tuberculosis.

Over a four-year period, 28 patients with abdominal tuberculosis were seen, of whom 24 were immigrants and 22 under 45 years. Emergency surgery was carried out in 10 patients; another 14 had elective laparotomy. The diagnosis was suspected pre-operatively in 75 per cent of those having elective surgery and 10 per cent of those having emergency laparotomy. Perforated ileal strictures were found in 30 per cent of those with acute symptoms. Half of those with chronic disease had hyperplastic ileocaecal disease and half tuberculous peritonitis. Positive histology was obtained in 23 patients, but culture was positive in only four. The only death was of an elderly white man with a perforated ileal stricture. The four patients treated without surgery showed a rapid symptomatic response to antituberculous drugs.

Endoscopic balloon dilatation of colonic anastomotic strictures.

Nine postoperative colonic and rectal strictures were treated using dilatation balloons passed over a guide-wire introduced endoscopically. Six strictures resolved after a single dilatation. The method is simple, safe, effective and avoids further surgery.

Tuberculous perforation of the small bowel.

Small bowel perforation occurs in up to 2 percent of patients with abdominal tuberculous. Patients present with an acute abdomen. Resection of the diseased segment and 18 months treatment with anti-tuberculosis drugs is recommended.

The use of varicography to identify the sources of incompetence in recurrent varicose veins.

We have studied patients with recurrent varicose veins which were incompletely controlled by a thigh tourniquet. We used varicography, (a phlebogram via the varices), to detect sites of incompetence. Thirty patients (mean age 46 years) were investigated, 38 limbs being subjected to varicography and surgery. A primary operation had been performed between 3 months and 30 years earlier. A non-thrombogenic contrast medium, sodium meglumine ioxaglate 320 (Hexabix 320) was used. Metal markers were placed alongside the limb to identify the site of perforating veins on the phlebograms. The principal value of the technique was in the identification of mid-thigh perforator incompetence (MTPI) as we cannot diagnose this accurately by clinical or Doppler-ultrasound examination. Varicography demonstrated MTPI in 15/38 limbs (39%) and in only one thigh was this not confirmed at exploration. Varicography can demonstrate short saphenous incompetence and this was mainly of value in 3 patients who had previously undergone attempted short saphenous ligation; in all 3 the short saphenous vein was present and had not been ligated. The technique was less useful in demonstrating recurrence in the groin. Overall varicography influenced the operation performed in 17/38 limbs (45%), its main value being in the diagnosis of MTPI.

The demonstration of saphenofemoral incompetence; doppler ultrasound compared with standard clinical tests.

Patients with primary varicose veins were examined by a combination of the standard tourniquet test with detection of reflux by Doppler ultrasound. Results were compared with standard clinical tests: impulse or thrill at the saphenous opening on coughing, tap impulse at the groin, and the 'Trendelenburg' tourniquet test. The state of competence of the saphenofemoral junction was noted at operation. One hundred and sixty-one limbs of 105 patients were studied. The saphenofemoral junction was incompetent in 132/161 limbs (82 per cent) and was judged competent in 29/161 limbs (18 per cent). The combined Doppler and tourniquet test assessed the saphenofemoral junction correctly in 82 per cent of limbs and was more accurate than all the other tests. The test had good sensitivity (0.9) but poor specificity (0.45). Poor specificity was a feature of all the tests except for thrill which was a highly insensitive test. The combined Doppler and tourniquet test appears to be the most simple, rapid and accurate means of detecting saphenofemoral incompetence.