Mild asymptomatic intrahepatic biliary dilation after cholecystectomy, a common incidental variant.

OBJECTIVE: The purpose of this study is to evaluate the prevalence of intra- and extrahepatic ductal dilatation in asymptomatic individuals after cholecystectomy. METHODS AND MATERIALS: This IRB-approved retrospective cohort study evaluated the prevalence of intra- and extrahepatic biliary dilation in 77 consecutive post cholecystectomy patients who had CT obtained in the portal venous phase. These were then compared to age and sex matched control patients. Two radiologists in consensus blinded to surgical history evaluated the intrahepatic ducts qualitatively for dilatation. A single radiologist using the best of three orthogonal planes measured the extrahepatic ducts. Extrahepatic ducts were considered dilated if >7 mm plus 1 mm/decade after 60 years. T tests and chi-squared tests were performed. RESULTS: Cholecystectomy patient duct patterns: normal ducts 26% (20/77); intra- and extrahepatic dilation 31.2% (24/77); intrahepatic dilation only 18.2% (14/77); extrahepatic dilation only 24.7% (19/77). Control patient duct patterns: normal ducts 88.3% (68/77); intra- and extrahepatic dilation 2.6% (2/77); intrahepatic dilation only 2.6% (2/77); extrahepatic dilation only 6.5% (5/77). All intrahepatic ductal dilatation was mild. Total intrahepatic dilation: 49.4% (cholecystectomy); 5.2% (control patients). The relative risk of intrahepatic ductal dilation in cholecystectomy patients was 9.5:1. Increased prevalence of intra- and extrahepatic dilation in cholecystectomy patients was statistically significant (p < 0.0001). Average extrahepatic duct was 7.8 mm (cholecystectomy) and 5.3 mm (control patients) (p < 0.001). CONCLUSION: Mild intrahepatic biliary dilation in the setting of cholecystectomy is very common, and if not associated with clinical or biochemical evidence of obstruction is likely of no clinical significance.

Eosinophilic Esophagitis with Dysphagia and Food Impaction in a Young Adult.

BACKGROUND: Eosinophilic esophagitis (EoE) is an emerging esophageal disease associated with dysphagia and food impaction. Practice guidelines have only recently been developed. It affects 1/1000 individuals, predominantly young men. As this demographic represents a substantial portion of the military aviation population, aerospace medicine clinicians should be familiar with this diagnosis when evaluating dysphagia or impactions. CASE REPORT: A 23-yr-old Caucasian man, a U.S. Air Force air traffic controller, presented to Flight Medicine following an episode of food impaction requiring evaluation in the local emergency department. The patient reported a 5-yr history of recurrent episodes of food lodging in his throat, requiring fluid and body repositioning for resolution. Medical history was significant for eczema. Upper endoscopy revealed an abnormal esophagus with macroscopic features of EoE and biopsies were also consistent with EoE. After further work-up, the patient was diagnosed with EoE and treated. Significant symptom improvement was noted after 2 mo of therapy. DISCUSSION: This case outlines the evaluation of food impaction as well as the diagnostic criteria for EoE, which is a disease that affects patients with demographics common to the military aviation community. As the diagnostic and treatment guidelines for EoE are relatively new, it may easily be overlooked by the primary care physician, causing a delay in subspecialist consultation, thus delaying treatment. EoE is a condition with symptoms that pose high risk to the performance of aircrew duties; therefore, flight surgeons must be familiar with the aeromedical standards that accompany this diagnosis.

Complete Heart Block in a Patient With Metastatic Papillary Thyroid Carcinoma.

Following a 2-day history of exertional dyspnea and palpitations, diagnostic images revealed a soft tissue mass in the right ventricular overflow tract. Can you guess the cause?