Computed tomography findings of internal hernia after gastric bypass that may precede small bowel obstruction.

PURPOSE: This study evaluates computed tomography signs of internal hernia in gastric bypass patients, including several previously unreported signs suggestive of internal hernia. METHODS: Eighteen patients with surgically proven internal hernia were included in the study cohort. The signs analyzed included the mesenteric swirl, hurricane eye, mushroom sign, and dilated small bowel loops, as well as previously non-investigated signs such as bowel wall edema, engorged mesenteric vessels, engorged mesenteric lymph nodes, and hazy mesenteric fat. We also separately examined internal hernia patients without overt small bowel obstruction (SBO), since these are the patients most likely to get overlooked by radiologists. RESULTS: The most prevalent sign in all internal hernia patients was mesenteric vessel engorgement, seen in approximately 79-84 % of patients overall and 73-75 % of patients without overt SBO. The level of agreement between our two readers for the eight total signs reviewed was all moderate to substantial (using Cohen kappa values), reflecting their reliability as markers of internal hernia. The highest level of agreement was seen in vessel engorgement at 0.91, followed by three other signs [hurricane eye, SBO, bowel edema] with levels of agreement at 0.86. CONCLUSIONS: We conclude that more subtle signs of internal hernia should be included in radiologist search patterns for patients with internal hernia, especially those presenting multiple times for abdominal pain, as these may reflect surgically correctable intermittent herniations.

Irinotecan combined with gemcitabine, 5-fluorouracil, leucovorin, and cisplatin (G-FLIP) is an effective and noncrossresistant treatment for chemotherapy refractory metastatic pancreatic cancer.

BACKGROUND: Single agents have only modest activity as treatment for metastatic pancreatic cancer with response rates of less than 10% and median survivals of less than 6 months. Evaluations of single-agent gemcitabine and rubitecan as second-line treatment for relapsed pancreatic cancer have reported good patient tolerability and median survivals of 3.85 months and 4.7 months, respectively. Regimens incorporating two drugs have demonstrated encouraging activity and clinical impact compared with single-agent therapy. G-FLIP is a regimen designed to incorporate four active single agents into a tolerable and active combination. This analysis is a retrospective evaluation of the efficacy and safety of the G-FLIP regimen as second-line chemotherapy in a series of consecutively treated patients with metastatic pancreatic cancer. METHODS: G-FLIP was administered over 48 hours and repeated every 2 weeks. Day 1 treatment consisted of sequentially administered gemcitabine 500 mg/m(2), irinotecan 80 mg/m(2), leucovorin 300 mg, 5-fluorouracil (5-FU) 400 mg/m(2) bolus followed by infusional 5-FU 600 mg/m(2) over 8 hours. Day 2 treatment consisted of leucovorin 300 mg and 5-FU 400 mg/m(2) bolus, followed by cisplatin 50 to 75 mg/m(2), and then infusional 5-FU 600 mg/m(2) over 8 hours. RESULTS: Thirty-four patients with histologically confirmed metastatic pancreatic cancer were consecutively treated. The median patient age was 64.5 years (range 41-82 years) and all patients had objective disease progression on prior therapy: 32 patients had disease progression with gemcitabine and 31 had disease progression with a gemcitabine/5-fluorouracil/cisplatin combination. Grade 3-4 hematological toxicities included anemia (23%), thrombocytopenia (53%), and neutropenia (38%). There were no grade 3-4 neutropenic fevers, treatment-related mortalities, or withdrawals. Nonhematological grade 3-4 toxicities were rare: nausea/vomiting (3%), neurotoxicity (3%), nephrotoxicity (6%), and diarrhea (3%). Based on RECIST criteria a partial response (PR) was attained in eight patients (24%) and seven patients had stable disease (SD). Seven and six patients who attained a PR or SD, respectively, had disease progression with prior gemcitabine-based therapy. The median time to disease progression for all 34 patients was 3.9 months and 5.9 months for the eight patients who attained a PR. Median overall survival for all 34 patients was 10.3 months. CONCLUSION: Adding a single new drug such as irinotecan to the same first-line chemotherapy combination upon disease progression may be an important alternative to switching to different drug classes for treatment of relapsed/resistant cancer. The promising clinical outcomes and moderate toxicity associated with G-FLIP in this heavily pretreated group warrant development of this novel regimen including tests as first-line therapy in patients with diseases likely to be responsive to the drugs contained in this combination.

An unusual case of diverticulitis complicating pregnancy at 33 weeks' gestation.

A 38-year-old para 2 presented with the gradual onset of nausea vomiting and increasing left lower quadrant pain, at 33 weeks' gestation. She was known to have uterine leiomyomas, with ultrasonography depicting an 8-cm intramural fundal leiomyoma. In addition a left lateral nondiscrete 10 x 8-cm mass was depicted at the point of maximum tenderness. Magnetic resonance imaging (MRI) demonstrated diverticulosis of the descending and sigmoid colon. The patient remained afebrile and received repeated doses of intramuscular analgesics and was cleared by the surgical consultant, only to be readmitted with similar symptomatology 24 hours later. Subsequently, following repeat discharge she delivered at 34 weeks' gestation, and developed a small bowel obstruction during the immediate postpartum course. With the continued finding of a left lower abdominal mass and computed tomography findings suggestive of perforated sigmoid diverticulitis and resulting small bowel obstruction, laparotomy was performed. Multiple adhesions and phlegmon sequelae of chronic perforation of the sigmoid were confirmed, and a diverting descending colostomy and Hartman's procedure were performed. We present unusual MRI findings of diverticulitis in the third-trimester and review the literature pertaining to this unusual complication of pregnancy.

The How Are You? scale: a quality-of-life outcomes measure for routine practice.

The How Are You? scale, a quality-of-life outcomes self-report measure to be completed by patients, was developed to address the concerns of the mental health consumer movement. Specific concerns included using less technical language in assessing mental health problems and developing a collaborative dialogue between clinician and patient. The How Are You? scale is a user-friendly instrument that allows patients to be actively involved in their assessment and treatment process. To implement the How Are You? scale into a recording and measurement system, its psychometric properties were assessed using two samples: (1) An employee group from The Menninger Clinic was used to assess internal consistency and stability, and (2) a patient group from The Menninger Clinic was used to assess known-group and discriminant validity, as well as sensitivity to change. The How Are You? scale was found to have good internal consistency and stability and good known-group and discriminant validity. It was also found to be sensitive to change. Although data continue to be collected at The Menninger Clinic, initial indications are that the How Are You? scale is a psychometrically sound outcomes measurement tool.

Which treatments help? The patient's perspective.

In an effort to determine which specific aspects of treatment might account for patient satisfaction, the authors developed the Components of Treatment Questionnaire. This measure, which was administered to 500 adult inpatients along with the Client Satisfaction Questionnaire (CSQ-8; Larsen, Attkisson, Hargreaves, and Nguyen, 1979), asked patients to assess the helpfulness of their treatment. Convinced that patient input is pertinent to program design, the authors later surveyed 46 patients on treatments that they perceived as helpful and would like to receive. Respondents identified individual relationships and problem-focused therapies as the most helpful aspects of treatment.

Experience with breast biopsies using the Advanced Breast Biopsy Instrumentation system.

OBJECTIVE: A retrospective review of our experience with advanced breast biopsy instrumentation (ABBI) was undertaken to evaluate its efficacy for excisional breast biopsy of lesions detected on mammography. To our knowledge, experience with ABBI has not been previously reported in the radiology literature. MATERIALS AND METHODS: Biopsies using the ABBI system and an adapted dedicated table were performed in 53 patients who had 54 mammographically evident lesions. Samples were obtained with cannulas ranging in size between 5 and 20 mm. Indications for biopsy were calcifications (n = 22) and masses (n = 31). RESULTS: Forty-five specimens (44 patients) had benign results at pathology: 15 specimens were diagnosed as fibroadenoma, 15 as cystic breast disease, and four as reactive lymph nodes; the remaining 11 specimens had benign diagnoses of adenosis, fibrosis, and hyperplasia. The average specimen size was 4.8 cm in greatest longitudinal dimension. One patient had a nondiagnostic biopsy for calcifications later found to be dermal. Seven patients were diagnosed as having breast cancer; in six of these, the tumor involved the margins of the specimen. One patient had marked atypia that required reexcision for the diagnosis of intraductal carcinoma to be made. CONCLUSION: The ABBI procedure is a more invasive and less readily available procedure than core needle biopsy for sampling of benign breast lesions. In seven cases of malignancy diagnosed at breast biopsy, the ABBI technique completely excised only a single lesion. In our experience, the ABBI procedure offered no advantages over core needle biopsy for either benign or malignant lesions.

Use of magnetic resonance urography.

OBJECTIVES: Magnetic resonance urography (MRU) is a new technique that uses heavily weighted T2 coronal images with fat suppression pulse. Urine appears white on MRU, resembling an intravenous urogram (IVU). Contrast agents are not necessary. This study describes the use of MRU in the diagnosis and treatment of patients with hematuria. METHODS: One hundred six patients with microscopic or gross hematuria and 6 normal volunteers underwent MRU between 1992 and 1995. A modified, heavily weighted T2 technique with intravenous administration of furosemide and ureteral compression was used. Thirty-two patients had other imaging techniques as well for comparison. RESULTS: MRU provided high-resolution images in almost all cases; 73 (69%) had a normal MRU. Significant findings in the 33 patients with abnormalities included renal cysts in 17 (51%), renal cell carcinoma in 6 (18%), transitional cell carcinoma in 5 (15%), ureteropelvic junction obstruction in 3 (9%), and stones causing obstruction in 6 (18%). Five patients with renal failure also had good visualization of the entire urinary tract. MRU was comparable to other imaging modalities except in identifying nonobstructing calculi. CONCLUSIONS: MRU provides an alternative to conventional imaging of the urinary tract, especially in those patients who have contraindications to ionizing radiation and contrast agents. Improvements in resolution, technique, and cost have to be addressed before it can be used regularly in urologic practice.

Prospective evaluation of colonic obstruction with computed tomography.

BACKGROUND: To determine whether computed tomography (CT) can satisfactorily diagnose and evaluate patients with suspected colonic obstruction. METHODS: Seventy-five patients with suspected colonic obstruction were evaluated prospectively by CT and compared with the gold standards of surgery and/or endoscopy in 65 patients, clinical course in nine, and contrast enema (CE) in one. A limited comparison between CT and CE (26) patients was also made in those patients who had both studies. RESULTS: CT successfully diagnosed colonic obstruction in 45 of 47 patients (96% sensitivity). Pseudo-obstruction was correctly diagnosed in 26 of 28 patients (93% specificity). CT correctly localized the point of obstruction in 44 of 47 patients (94%). CE successfully diagnosed obstruction in only 20 of 25 patients (80% sensitivity). CONCLUSION: In this study, CT proved to be a satisfactory modality in evaluating patients with suspected colonic obstruction. CT may in certain circumstances be preferable to the traditional CE in evaluating these patients.

Visceral fat and race-dependent health risks in obese nondiabetic premenopausal women.

Our previous finding that a waist-to-hip ratio (WHR) >0.85 was not associated with similar health risks in black, compared with white, obese premenopausal non-diabetic women of similar fatness is attributed to either 1) a different relationship between WHR and visceral adiposity or 2) differences in the relationship between visceral adiposity and the metabolic abnormalities of obesity. We measured visceral (VAT) and subcutaneous adipose tissue (SCAT) areas at midwaist in 25 black and 25 white obese nondiabetic pre-menopausal women with similar BMI, percentage body fat, and wide range of WHR (0.7-0.95 for black women and 0.7-0.9 for white women) and then compared insulin sensitivity index (SI), glucose and insulin areas under the 2-h curve (AUCs) during an oral glucose tolerance test (OGTT), and blood lipids in the two groups before and after adjustments for total body and visceral adiposity. After adjusting for total body fat mass (FM), obese black women had significantly less VAT (by 32 cm2) and lower VAT/SCAT for any given WHR. The regression equations predicting the SI the glucose and insulin AUCs, and the triglyceride and HDL cholesterol levels from regional adipose tissue measurements (VAT, SCAT, or VAT/SCAT) and from total body fat (FM or percentage body fat) had slopes that were not significantly different for black and white women. LDL cholesterol levels were independently related to VAT in black but not in white women. The black women had a similar SI insulin AUC, and triglyceride levels but significantly lower glucose AUC and higher HDL cholesterol levels (P < 0.001), after adjusting for VAT and FM. Regression analysis of the pooled data showed that high VAT and high VAT/SCAT, but not SCAT, predicted lower SI higher glucose and insulin AUCs during OGTT, and higher triglyceride levels, independent of total adiposity. We conclude that while increases in VAT and VAT/SCAT adversely affect metabolism in both black and white obese premenopausal women, similar levels of total body and visceral adiposity are associated with different metabolic risk factors in these groups.

Abdominal CT findings when the superior vena cava, brachiocephalic vein, or subclavian vein is obstructed.

OBJECTIVE: We evaluated findings on contrast-enhanced abdominal CT scans that suggest obstruction of the superior vena cava, brachiocephalic vein, or subclavian vein. SUBJECTS AND METHODS: We conducted a retrospective review of 22 patients with superior vena caval, brachiocephalic vein, or subclavian vein obstruction and analyzed the upper abdominal images on a chest CT scan or an abdominal CT scan. We assessed collateral vessels in the upper abdomen to answer the following question: Did enhancement approach undiluted IV contrast or were there other findings? In the second part of our study, we conducted a prospective review of abdominal CT scans of 200 patients without known mediastinal disease or known upper extremity venous occlusion to determine the frequency of abnormal enhancement of these vessels in a healthy population. RESULTS: The groups of collateral vessels revealed on abdominal CT scans were azygos or hemiazygos veins, internal mammary veins, lateral thoracic and superficial thoracoabdominal veins, vertebral venous plexus veins, and small mediastinal collateral veins. In the retrospective series, one patient had focal enhancement of the liver and early inferior vena caval enhancement due to collateral vessels. In the prospective series, abdominal CT scans of two patients (1%) revealed dense undiluted enhancement of one or more groups of collateral vessels: One patient had an ipsilateral pacemaker, and the other patient had an anterior neck phlegmon to the upper mediastinum. Both conditions may have been factors in the revealing of the collateral vessels. Two other patients (1%) in the prospective series had mild to moderate vessel enhancement that was less than that from undiluted contrast material. In one of these patients, the enhancement was related to abdominal wall hyperemia after surgery. In the other patient, enhancement may have been the result of ipsilateral axillary nodes. CONCLUSION: On upper abdominal CT scans, dense undiluted contrast material in the collateral vessel groups that we studied suggests possible obstruction of the superior vena cava, brachiocephalic vein, or subclavian vein.

Detection of intestinal ischemia in patients with acute small-bowel obstruction due to adhesions or hernia: efficacy of CT.

OBJECTIVE: The purpose of this study was to determine whether CT can be used to diagnose ischemia of the small intestine in patients with small-bowel obstruction due to adhesions or hernia. SUBJECTS AND METHODS: During a 12-month period, 60 patients underwent surgery for complete or high-grade small-bowel obstruction due to adhesions or hernia, and 29 (48%) had evidence of associated intestinal ischemia. All of these patients had been preoperatively diagnosed by CT as having high-grade small-bowel obstruction. At the same time, a prospective determination was made based on the CT as to whether there was any associated intestinal ischemia. All CT scans were performed within 24 hours of the operation. A CT diagnosis of ischemia was based on the presence of two or more of the following signs: bowel-wall thickening, high attenuation of the bowel wall on unenhanced CT scans, mesenteric edema or fluid, asymmetric bowel-wall enhancement on i.v. contrast-enhanced CT scans, pneumatosis, or portal venous gas. Results of the CT examination and surgical findings were then compared. Further evaluation was done with a retrospective multivariate discriminant analysis. RESULTS: Ischemia was prospectively diagnosed on the basis of CT findings in 41 (68%) of the 60 patients. There were no false-negative CT diagnoses (sensitivity, 100%); however, there were 12 CT diagnoses that were false-positive (specificity, 61%). The multivariate analysis corroborated the prospective results by showing high sensitivity (90%) and diminished specificity (50-64%). Bowel-wall thickening and high attenuation of the bowel wall were the most important signs of ischemia on unenhanced CT scans, whereas abnormal bowel-wall enhancement and mesenteric fluid correlated best on enhanced CT examinations. CONCLUSIONS: CT is a sensitive but not completely specific preoperative indicator of intestinal ischemia in patients with small-bowel obstruction due to hernias or adhesions.

Role of CT in evaluating patients with small-bowel obstruction.

The accurate and rapid diagnosis of acute small-bowel obstruction has troubled surgeons and radiologists for more than a century. With the advent of CT, solving the problem is now a possibility. CT can accurately diagnose obstruction, determine the likely cause and location, and even suggest whether there is associated bowel ischemia or strangulation.

Distinction between postoperative ileus and mechanical small-bowel obstruction: value of CT compared with clinical and other radiographic findings.

OBJECTIVE: The expeditious diagnosis of complete and partial mechanical small-bowel obstruction, as opposed to paralytic ileus, during the immediate postoperative period may be difficult on the basis of clinical and plain film radiographic findings. For this reason, we prospectively evaluated the use of CT in this setting and compared it with the clinical and plain film evaluations as well as with various contrast examinations. SUBJECTS AND METHODS: Thirty-six postoperative patients with signs and symptoms of paralytic ileus or mechanical small-bowel obstruction were examined clinically and had plain abdominal radiographs. Based on the findings of these examinations, the surgeon assigned patients to one of the following categories: (1) paralytic ileus, (2) indeterminate, (3) partial mechanical obstruction, or (4) complete mechanical obstruction. CT scans were obtained within 24 hr of the initial diagnostic studies, and patients were then recategorized according to the above classification solely based on CT findings. Initial examination results were then compared with the CT results. In addition, the results of contrast studies, namely, enteroclysis and barium enema, performed after CT small-bowel series, were evaluated. The gold standard for diagnosis was laparotomy in 20 patients, clinical course and follow-up in 13 patients, and clinical course and contrast studies in the other three patients. RESULTS: CT was effective (sensitivity and specificity, 100%) in distinguishing between postoperative ileus and complete mechanical small-bowel obstruction. The combined clinical and plain film findings were often confusing and nondiagnostic (sensitivity, 19%). CT was also valuable in diagnosing and distinguishing partial mechanical small-bowel obstruction from paralytic ileus. Contrast studies (enteroclysis) in four patients with partial mechanical small-bowel obstruction were useful in grading the degree and severity of the obstruction. CONCLUSION: Our results suggest that in the immediate postoperative period, CT is the method of choice for diagnosing mechanical small-bowel obstruction and distinguishing it from paralytic ileus. Contrast studies are useful in further evaluating partial mechanical small-bowel obstruction.

MR urography: technique and application.

PURPOSE: To evaluate a magnetic resonance (MR) technique for depicting the kidneys and urinary tract. MATERIALS AND METHODS: Fourteen patients with urinary tract obstruction and 20 without obstructions were examined with a modified, heavily T2-weighted fast spin-echo pulse sequence (MR urography). In addition, six healthy volunteers underwent modified MR urography with intravenous administration of furosemide and ureteral compression prior to imaging. RESULTS: MR urography provided high-resolution images of the kidneys and urinary tract in all patients with obstruction with intact collecting systems. Anatomic anomalies were depicted in two patients. Intraluminal neoplasia was well demonstrated in both obstructed and nonobstructed systems (n = 4). Furosemide-enhanced MR urography provided fine anatomic and functional detail of both the kidneys and urinary tract (n = 6). CONCLUSION: MR urography may provide an alternative to more conventional urinary tract imaging techniques. It does not require ionizing radiation or iodinated contrast material. When combined with furosemide and ureteral compression, MR urography provides fine detail and reflects function.

Active pulmonary tuberculosis in patients with AIDS: spectrum of radiographic findings (including a normal appearance).

PURPOSE: To assess the efficacy of chest radiography in the detection of active pulmonary tuberculosis in patients with acquired immunodeficiency syndrome (AIDS). MATERIALS AND METHODS: Initial interpretations of chest radiographs of 133 adult patients with AIDS and positive sputum or bronchoalveolar lavage cultures for Mycobacterium tuberculosis were reviewed. Radiographic findings were correlated with CD4 T-cell counts, sputum stains for acid-fast bacilli (AFB), and antituberculous drug sensitivity. RESULTS: Forty-eight (36%) patients had a primary M tuberculosis pattern, 38 (28%) had a postprimary M tuberculosis pattern, 19 (14%) had normal radiographs, 17 (13%) had atypical infiltrates, seven (5%) had minimal radiographic changes, and four (3%) had a miliary pattern. Normal chest radiographs were seen for 10 (21%) of 48 patients with less than 200 T cells per microliter and one (5%) of 20 patients with more than 200 T cells per microliter. Drug sensitivity and sputum staining for AFB did not correlate with radiographic findings. Overall, 19% of cases had multidrug resistance to antituberculous medications. CONCLUSION: Chest radiographs did not suggest active tuberculosis in 43 (32%) of 133 AIDS patients with active pulmonary tuberculosis.

Idiopathic esophageal ulceration in the acquired immunodeficiency syndrome: radiologic reappraisal in 10 patients.

Idiopathic esophageal ulceration in patients with AIDS has previously been described. Establishing this diagnosis is important because of the excellent response of these ulcers to corticosteroid therapy. We studied 10 such patients with esophagography and endoscopy. HIV was isolated from the ulcer base in six of the 10 patients utilizing various techniques including in situ hybridization. No other organisms were found. All of the ulcers were in the distal half of the esophagus and were solitary in eight of the 10 patients. The solitary ulcers were large (2.5 x 2.0 cm to 12 x 9 cm) and deep (> 0.5 cm) with undermined margins. In three patients, fistulae arose from the distal esophagus and crossed the gastroesophageal junction. In one patient, a huge idiopathic ulcer perforated into the mediastinum. These latter findings are not seen in the more common ulcerating AIDS esophagitides due to herpes simplex and cytomegalovirus.

CT of small-bowel obstruction: value in establishing the diagnosis and determining the degree and cause.

OBJECTIVE: The early diagnosis of small-bowel obstruction is critical in preventing complications, particularly strangulation. Traditionally, the clinical diagnosis of small-bowel obstruction has depended on plain film confirmation. Unfortunately, findings on the plain film may not be confirmatory in 20-52% of cases. The purpose of this study was to determine whether CT is superior to the traditional clinical-radiographic evaluation in prospectively establishing the diagnosis, severity, and cause in cases of suspected obstruction of the small bowel and to see what impact this information might have on treatment, costs, and the need for additional gastrointestinal contrast studies. SUBJECTS AND METHODS: Physicians from three surgical services referred all patients with suspected small-bowel obstruction for plain film and CT evaluation. Eight-five patients were evaluated on 90 occasions during an 11-month period. Obstruction was classified on the basis of clinical and plain film findings as absent, indeterminate, or present (partial or complete). CT scans were obtained in all patients and were interpreted and graded without knowledge of the clinical-radiographic classification. The results of gastrointestinal contrast studies (barium enema, small-bowel series, and enteroclysis) performed in 21 cases were also compared. The gold standard for the diagnosis was surgical findings in 61 cases and clinical course in 29 cases. RESULTS: On the basis of the combined clinical-radiographic findings, the diagnosis was complete obstruction in 21 of 46 cases (sensitivity, 46%; confidence interval (CI), 32-60%). When CT was used, the diagnosis was established in all 46 cases (sensitivity, 100%; CI, 86-100%). In the 25 cases in which the traditional evaluation failed, the early CT diagnosis of complete obstruction prevented a 12-72 hr delay in surgery with its attendant increased morbidity, mortality, and costs. On the basis of the combined clinical-radiographic findings, partial obstruction of the small bowel was diagnosed in six of 20 cases (sensitivity, 30%), whereas all cases were detected with CT. False-positive CT findings for complete obstruction of the small bowel occurred in three cases of paralytic ileus (one each due to small-bowel infarction, lower lobe pneumonia, and peritonitis due to rupture of the urinary bladder). One case of colonic obstruction due to carcinoma in the hepatic flexure was mistakenly diagnosed as partial obstruction of the small bowel. The clinical and plain film evaluation was never precise enough to provide the exact location or cause of small-bowel obstruction. Gastrointestinal contrast studies provided additional useful information regarding colonic abnormalities (four cases), functional grading of partial obstruction of the small bowel (six cases), and exclusion of a false-positive CT diagnosis of complete obstruction in a case of reflex ileus. CONCLUSION: CT is sensitive for diagnosing complete obstruction of the small bowel and for determining the location and cause of obstruction. In comparison, the traditional clinical and plain film evaluation is relatively insensitive. CT should be used when the results of clinical and plain film evaluation are inconclusive. Gastrointestinal contrast studies play an important diagnostic role in partial obstruction of the small bowel and in colonic obstruction with predominant small-bowel dilatation.

Elevated CA19-9 in a case of Mirizzi's syndrome.

At levels greater than 1000 U/ml, the tumor-associated antigen CA19-9 has a specificity approaching 100% for malignant disease. A 67-yr-old woman with known cholelithiasis presented with painless jaundice and a CA19-9 of 1320 U/ml. The diagnosis of Mirizzi's syndrome was made at laparotomy, and the postoperative level fell rapidly to normal. Mirizzi's syndrome should be included among the few benign disorders which can yield such elevations in the CA19-9.