Postsurgical biliary tract complications.

Cholecystectomy and other biliary tract operations are being performed with an increasing frequency due to the prevalence of gallstones and pancreaticobiliary disorders among the aging population of the United States. Even in the current era of modern medicine, however, a wide spectrum of postsurgical biliary complications are encountered. Most are the result of preventable iatrogenic trauma or technical mishaps that occur with a much higher incidence during laparoscopic cholecystectomy than the conventional open procedure. These include bile leakage from an overlooked transection of normal or aberrant bile ducts, obstructive jaundice due to inadvertent ligation of the common duct or its postsurgical stricture, instrumentation injuries induced during biliary tract exploration, and the various types of biliary fistulas. These lesions are detectable by intraoperative or T-tube cholangiography, if the examination is performed and interpreted correctly. In most instances, however, the postoperative evaluation of the abdomen by computed tomography or ultrasonography will provide the initial clues to an otherwise unsuspected lesion. Radiologic imaging and interventional techniques play a crucial role in the diagnosis and management of postsurgical biliary tract complications, as illustrated in this review article.

Gastric cancer. Radiologic diagnosis.

The development and refinement of double-contrast barium techniques over the past two decades have dramatically improved the radiologist's ability to detect gastric cancer and characterize gastric ulcers. This article presents the radiologic findings of both early and advanced gastric cancer and offers guidelines for differentiating benign versus malignant gastric ulcers.

Gastric cancer. Radiologic staging.

CT scan and EUS play complementary roles in staging gastric cancer. CT scan is initially performed to detect local and distant metastases. Depending on institutional expertise, EUS may be considered for local staging. Laparoscopic staging may also be helpful in select patients. It is hoped that further improvements in these techniques will improve the ability to stage gastric cancer and thereby optimize patient treatment and outcome.

Detection of occult esophageal narrowing with a barium tablet during chest radiography.

Dysphagia is a delayed symptom of esophageal constriction and often appears after the luminal diameter is reduced to less than 10 mm. Earlier diagnosis of benign or malignant strictures while clinically silent would be desirable; hence we investigated the detectability of occult esophageal lesions with the aid of an ingested barium tablet during routine chest radiography. We prospectively examined 300 patients older than 40 years, who were referred for chest films because of indications unrelated to the upper gastrointestinal tract. Each patient was instructed to swallow a 12.5-mm barium tablet with 100 mL of water immediately prior to the exposure of posteroanterior and lateral chest films. Radiographs of 17 patients (5.6%) revealed intraesophageal retention of the tablet, and their prompt evaluation with double-contrast esophagrams confirmed various structural or functional abnormalities in 15 patients. Therefore, the oral administration of a barium tablet during routine chest radiography is a simple efficacious method to assess esophageal patency and detect occult narrowings from structural or functional causes.

Radiologic features of carcinomas arising in hiatal hernias.

OBJECTIVE: The aim of this study was to present the spectrum of clinical and radiologic manifestations of carcinomas that originate within hiatal hernias, to emphasize their increasing prevalence among the elderly patient population, and to assess the reasons for radiologic misdiagnosis. MATERIALS AND METHODS: Medical records and radiologic studies of 27 adult patients (15 men and 12 women; 54-83 years old [mean, 71 years old]) with surgically proven adenocarcinomas in the herniated proximal part of the stomach were reviewed. RESULTS: A hiatal hernia with intrinsic abnormalities suggestive of carcinoma was shown by upper gastrointestinal tract examination obtained before surgery in all 27 patients. A diagnosis of malignancy was reported at the time of examination for 24 patients (89%); for the remaining three patients, diagnosis was made by endoscopy. The predominant feature, seen in 15 patients (56%), was an infiltrative process that caused deformity and rigidity of the hiatal hernia in conjunction with thickened, nodular mucosa. The intrahernial tumor appeared as a well-demarcated sessile polyp or lobulated mass in nine patients (33%) and as ulcerations and eccentric wall thickening in three patients (11%). All errors were perceptive in nature. On review, we saw minimal evidence of infiltration or small polypoid masses. CONCLUSION: Although some of the radiologic abnormalities were minimal, our review of 27 cases in a biphasic upper gastrointestinal tract series resulted in detectable radiographic findings of carcinomas associated with hiatal hernias for all cases. Meticulous assessment of the herniated fundus and gastroesophageal regions is crucial for the detection of such tumors.

Radiologic investigation of acute inflammatory and infectious bowel disease.

Definitive diagnosis of infectious or idiopathic inflammatory bowel disease ultimately rests on histologic and bacteriologic documentation. Nevertheless, radiologic studies play an important role in the evaluation and management of patients with acute enterocolitis. Plain abdominal films can give a gross estimate of disease extent in the colon and detect complications, such as perforation or toxic megacolon. Double-contrast barium enema allows visualization of the mucosal pattern and the overall configuration of the bowel, which are important for determining the extent and severity of disease and its most likely cause. Cross-sectional imaging depicts the mural and mesenteric involvement as well as intraperitoneal complications of inflammatory bowel disease, thus providing a critically important perspective that complements the information afforded by endoscopic and conventional radiographic techniques.

Idiopathic localized dilatation of the ileum in adults: findings on barium studies.

OBJECTIVE: Idiopathic localized dilatation of the ileum is a rare entity characterized by a sharply demarcated segmental dilatation of the small bowel that is in line with the lumen. It is probably congenital in origin. Although more commonly diagnosed in children, it presents in adults as occult gastrointestinal (GI) bleeding or less often with abdominal pain. On pathologic examination, the mucosa may be ulcerated, but otherwise the wall is relatively normal. We analyzed the radiographic findings in nine previously unreported cases of this condition in adults. MATERIALS AND METHODS: Collaborative efforts resulted in the collection of nine cases from multiple institutions. In five cases, an enteroclysis had been performed; in three, a conventional small bowel series had been performed; and in one, the lesion was seen on a barium enema with reflux into the ileum. The mean age of patients was 52 years. In seven cases, pathologic correlation was available. In the other two patients, long-term clinical follow-up and repeat studies confirmed the diagnosis. Resected specimens showed a thin but otherwise normal wall with normal ganglion cells and nerve plexuses. Ulceration was noted in six of the seven resected cases. Two cases contained heterotopic gastric mucosa. GI bleeding and/or anemia was the most common (77%) presenting symptom. Abdominal pain and/or obstruction was present in slightly less than half the patients (44%). RESULTS: Lesions were 6-21 cm long and 4-13 cm wide, and all were located in the ileum. The dilated segments were bilobate in three cases, multilobate in three, spherical in two, and tubular in the other. The dilated area was always in line with the long axis of the bowel, not projecting to the side. No surrounding masses were seen. Except in three patients in whom ulcers were noted, the mucosa was normal. CONCLUSION: Idiopathic localized dilatation of the ileum should be suspected whenever a sharply demarcated area of lobulated small bowel dilatation is seen in a middle-aged patient with occult GI bleeding. The axial orientation distinguishes this condition from small bowel diverticula (including Meckel's). The lack of surrounding mass, mucosal irregularity, hypermotility, or fistulae help differentiate it from other causes of small bowel dilatation.

Passive hepatic congestion: cross-sectional imaging features.

Passive hepatic congestion is caused by stasis of blood within the liver parenchyma due to compromise of hepatic venous drainage. It is a common complication of congestive heart failure and constrictive pericarditis, wherein elevated central venous pressure is directly transmitted from the right atrium to the hepatic veins because of their close anatomic relationship (Fig. 1). The liver becomes tensely swollen as the hepatic sinusoids dilate and engorge to accommodate the backflow of blood. A variety of structural and functional hepatic derangements develop that have distinctive appearances on sonograms, CT scans, and MR images.

Radiologic evaluation of suspected gastrointestinal perforations.

Perforation of the alimentary tract may occur spontaneously in various gastrointestinal diseases or develop due to an ingested foreign body, iatrogenic complication, and blunt or penetrating injuries. The detection of extraluminal air on radiographs of the chest or abdomen is often the initial clue to the diagnosis. It may not, however, be visible when the perforation is small, rapidly sealed, or well contained. Further evaluation by special radiographic techniques, gastrointestinal studies using contrast media, or CT examination can demonstrate the site and nature of the perforation. This article reviews the clinical features and methods for radiologic assessment of suspected perforations involving the upper gastrointestinal tract, small bowel, or colon and rectum.

Carcinoma arising in urinary bladder diverticula: imaging findings in six patients.

OBJECTIVE: Carcinoma arising within urinary bladder diverticula has a poorer prognosis than do neoplasms that originate within the main bladder lumen as a result of early transmural tumor infiltration. Imaging plays an important role in diagnosing and staging the disease. We describe the radiologic findings in six patients with pathologically proved diverticular carcinomas. MATERIALS AND METHODS: We reviewed the records of six patients who had radiologic examinations and surgically confirmed vesical diverticular carcinomas. The examinations included excretory urography in three patients, cystography in three patients, CT in five patients, and MR imaging in one patient. All patients had hematuria. Five patients had transitional cell carcinoma, and one patient had squamous cell carcinoma. RESULTS: Three of the tumors manifested as an intraluminal filling defect within a bladder diverticulum on excretory urograms or cystograms. In one patient, CT scans showed a concentric soft-tissue tumor in a diverticular neck. Correlative cystograms showed only smooth narrowing in this area. CT and MR imaging showed a tumor within a large diverticulum, which was not visualized on cystograms because of obstruction at the diverticular orifice. CONCLUSION: Imaging plays an important role in identifying bladder diverticula as a potential site of occult neoplasm.

Imaging manifestations of pleural tumors.

Although radiologic assessment of pleural tumors may be accomplished with several imaging modalities, the standard noninvasive techniques include chest radiography and computed tomography (CT). These examinations may be supplemented with magnetic resonance imaging and occasionally with ultrasound. Depending on the location, size, and underlying histologic features, pleural tumors may produce a spectrum of findings. CT is particularly useful in defining the location and extent of these masses. The authors present a review of basic pleural anatomy and imaging features of both benign and malignant pleural neoplasms. The pleural may be involved by one of several primary or metastatic tumors. Specific cell types are diffuse malignant mesothelioma (the most common plain radiographic findings are unilateral pleural effusion and pleural thickening), localized fibrous tumor (circumscribed, spherical or ovoid, noncalcified lesions arising in the pleural surface), metastatic disease (radiographic findings may mimic those of malignant mesothelioma), and uncommon neoplasms including thymoma and lymphoma. Among these various pleural tumors, metastatic disease represents the most common neoplasm.

Appendices epiploicae of the colon: radiologic and pathologic features.

Appendices epiploicae are adipose structures protruding from the serosal surface of the colon. They can be seen with abdominal radiography and cross-sectional imaging if the colonic wall is surrounded by intraperitoneal contrast material, ascites, or blood. Normal appendices epiploicae appear as lobulated masses of pericolic fat, usually 2-5 cm long and 1-2 cm thick. Their enlargement, deformity, or altered radiopacity may result from various pathologic processes that can originate locally or extend from adjacent viscera. In a series of 22 cases, appendices epiploicae were affected by spontaneous torsion and hemorrhagic infarct, calcification due to aseptic fat necrosis, primary or secondary inflammation, enlargement by lipomas or metastases, and incarceration in hernias. Disorders of appendices epiploicae are often manifested by nonspecific clinical signs and symptoms (eg, torsion is often mistaken for appendicitis or diverticulitis). These entities should be included in the differential diagnosis of any unexplained abdominal pain or pericolic lesions in adults.

Evolution of pulmonary pseudolymphomas: clinical and radiologic manifestations.

Solitary or multifocal pulmonary pseudolymphoma developed in two men and two women between 59 and 76 years of age. The lesions were detected incidentally in three patients and following a respiratory infection in the fourth. Follow-up radiographs and chest CT revealed gradual expansion of the opacities without cavitation, calcification, or pleural involvement. Histopathologic sections from open lung biopsies or resected segments showed dense alveolar and peribronchial infiltration by numerous mature lymphocytes and plasma cells surrounding reactive lymphoid follicles with true germinal centers. Their benign nature was confirmed by immunofluorescent studies showing polyclonal cell populations. No recurrence or malignant change occurred during 4- to 9-year periods of observation. The clinical and radiologic features of pulmonary pseudolymphoma are presented with a brief review of 54 previously reported cases.

Diverticulitis of the duodenum: clinical and radiological manifestations of seven cases.

Seven patients with duodenal diverticulitis were evaluated by computed tomography (CT) and various other abdominal imaging techniques. The series included four men and three women who ranged in age from 47 to 84 yr (mean: 65 yr). They had presented with epigastric or periumbilical pain, low-grade fever, leukocytosis, and loss of appetite and weight due to postprandial cramps or vomiting. In each instance, the abdominal CT examination proved crucial in the diagnosis of duodenal diverticulitis, with contained perforation or inflammatory changes involving the adjacent structures. Five patients underwent laparotomy while two others were treated conservatively with antibiotics and/or percutaneous drainage of peridiverticular abscess. The clinical and radiological features of this uncommon entity are herein described, along with a brief review of the medical literature regarding the current approach to its diagnosis and management.