CT enterography and fistulizing Crohn's disease: clinical benefit and radiographic findings.

BACKGROUND: To estimate the clinical benefit of CT enterography (CTE) in patients with fistulizing Crohn's disease and describe the appearance of fistulas at CTE. METHODS: Crohn's patients who had undergone CTE, which diagnosed an abscess or fistula, were identified. A gastroenterologist reviewed clinical notes prior to and following CTE to assess the pre-CTE clinical suspicion for fistula/abscess, and post-CTE alteration in patient management. A radiologist reassessed all fistula-positive cases, which were confirmed by a non-CT reference standard, to describe their radiologic appearance. RESULTS: Fifty-six patients had CT exams identifying 19 abscesses and 56 fistulas. There was no or remote suspicion of fistula or abscess at pre-imaging clinical assessment in 50% of patients. Thirty-four patients (61%) required a change in or initiation of medical therapy and another 10 (18%) underwent an interventional procedure based on CT enterography findings. Among 37 fistulas with reference standard confirmation, 30 (81%) were extraenteric tracts, and 32 (86%) were hyperenhancing compared to adjacent bowel loops. Most fistulas (68%) contained no internal air or fluid. CONCLUSION: CTE detects clinically occult fistulas and abscesses, resulting in changes in medical management and radiologic or surgical intervention. Most fistulas appear as hyperenhancing, extraenteric tracts, usually without internal air or fluid.

Correlation of radiographic and manometric findings in patients with ineffective esophageal motility.

BACKGROUND: Ineffective esophageal motility disorder (IEM) is a new, manometrically defined, esophageal motility disorder, associated with severe gastroesophageal reflux disease (GERD), GERD-associated respiratory symptoms, delayed acid clearance, and mucosal injury. Videoesophagram is an important, inexpensive, and widely available tool in the diagnostic evaluation of patients with esophageal pathologies. The efficacy of videoesophagography has not been rigorously examined in patients with IEM. The aim of this study was to determine the diagnostic value of videoesophagography in patients with IEM. METHODS: The radiographic and manometric findings of 202 consecutive patients presenting with foregut symptoms were evaluated. IEM was defined by strict manometric criteria. All other named motility disorders such as achalasia were excluded. Videoesophagography was performed according to a standard protocol. RESULTS: Of patients in this cohort, 16% (33/202) had IEM by manometric criteria. Of IEM patients, 55% (18/33) had an abnormal videoesophagram, while in 45% (15/33) this test was read as normal. Only 11% (15/137) of patients with a normal videoesophagram were found to have IEM. Sensitivity of videoesophagram was 54.6%, specificity 72.2%, positive predictive value only 27.7%, and negative predictive value 89.1% in the diagnosis of IEM. CONCLUSIONS: These data show that videoesophagram is relatively insensitive in detecting patients with IEM and should not be considered a valid diagnostic test for this disorder. We conclude that esophageal manometry is an indispensable diagnostic modality in the workup of a patient with suspected of IEM.

Laparoscopic repair of large type III hiatal hernia: objective followup reveals high recurrence rate.

BACKGROUND: Recent studies based on symptomatic outcomes analyses have shown that laparoscopic repair of large type III hiatal hernias is safe, successful, and equivalent to open repair. These outcomes analyses were based on a relatively short followup period and lack objective confirmation that the hernia has not recurred. The aim of this study was to compare the outcomes of laparoscopic and open repair of large type III hiatal hernia using both symptomatic evaluation and barium study to assess the integrity of the repair. STUDY DESIGN: Fifty-four patients underwent repair of a large type III hiatal hernia between 1985 and 1998. The surgical approach was laparotomy in 13, thoracotomy in 14, and laparoscopy in 27. An antireflux procedure was included in all patients. Symptomatic outcomes were assessed using a structured questionnaire at a median of 24 months and was complete in 51 of 54 patients (94%). A single radiologist, without knowledge of the operative procedure, assessed the integrity of the repair using video esophagram. Videos were performed at a median of 27 months (35 months open and 17 laparoscopic) and were completed in 41 of 54 patients (75%). RESULTS: Symptomatic outcomes were similar in both groups with excellent or good outcomes in 76% of the patients after laparoscopic repair and 88% after an open repair. Reherniation was present in 12 patients and was asymptomatic in 7. A recurrent hernia was present in 12 of the 41 patients (29%) who returned for a followup video esophagram. Forty-two percent (9 of 21) of the laparoscopic group had a recurrent hernia compared with 15% (3 of 20) of the open group (p < 0.001 log-rank value on recurrence-free followup). CONCLUSIONS: Laparoscopic repair of type III hiatal hernias is associated with a disturbingly high (42%) prevalence of recurrent hernia. More than half such recurrences have few, if any, symptoms.

Abnormal esophageal body function: radiographic-manometric correlation.

Stationary manometry is the gold standard for the evaluation of patients with suspected esophageal motility disorders. Comparison of videoesophagram in the evaluation of esophageal motility disorders with stationary motility has not been objectively studied. Two hundred two patients with foregut symptoms underwent stationary motility and videoesophagram. Radiographic assessment of esophageal motility was done by video recording of five 10-cc swallows of barium. Abnormal esophageal body function was defined by stasis of barium in the middle third of the esophagus on at least four swallows or stasis on at least three swallows in the distal third. Stationary manometry was performed using a five-channel water perfused system. Contraction amplitudes <25 mm Hg in any of the last two channels or the presence of simultaneous or interrupted waves in 10 per cent or more were considered to be abnormal. Sixty-two patients had abnormal manometry. Thirty-four patients also demonstrated abnormal videoesophagrams for an overall sensitivity of 55 per cent. The positive predictive value was 53 per cent; specificity was 79 per cent; and negative predictive value was 80 per cent. Sensitivity was greatest in patients with achalasia (94%) and scleroderma (100%) and in patients presenting with dysphagia (89%). Sensitivity was poor for nonspecific esophageal motility disorders. A videoesophagram is relatively insensitive in detecting motility disorders. It seems most useful in the detection of patients with esophageal dysfunction, for which surgical treatment is beneficial, and in those patients presenting with dysphagia.

Triple-contrast computed tomography in the evaluation of penetrating posterior abdominal injuries.

Routine exploration of stable patients who have penetrating injuries of the posterior abdomen results in a high rate of unnecessary operation. Prolonged observation, while safe, is expensive and potentially morbid in the event that a retroperitoneal injury has occurred and treatment is delayed. To evaluate these injuries, we have developed and employed a protocol for computed tomographic (CT) scanning of the abdomen employing oral, intravenous, and rectal administration of contrast material to visualize the retroperitoneal contents. Between Jan 1, 1985, and Dec 1, 1986, 40 patients were studied in this manner. In each case, the path of penetration could be determined exactly by tracing the course of air and hematoma through the tissues. All retroperitoneal organs could be evaluated well enough to exclude injuries requiring intervention. The majority of patients showed subcutaneous penetrations only. All six significant intra-abdominal injuries were diagnosed correctly and confirmed at laparotomy. All 34 patients deemed by CT not to have significant injury were observed for 72 hours, and all were discharged uneventfully. Triple-contrast CT appears to be of great value in the triage of penetrating posterior abdominal trauma into operative and nonoperative groups.

Computed tomography of posterior fossa trauma.

A group of 1,700 cases of head trauma were reviewed to determine the incidence of posterior fossa injuries and to assess the value of computed tomography (CT) in their diagnosis and management. In 57 cases (3.3%), the most significant and primary injuries were within the posterior fossa. These included epidural hematoma (EDH), acute and chronic subdural hematoma (SDH), and parenchymal hemorrhage and contusion of the cerebellum and brainstem. The prognosis varies with the location and severity of the injury. Brainstem injuries are associated with a high mortality rate. Computed tomography proves particularly useful in the early recognition of brainstem injury. The demonstration by CT of obliteration of the cisterns surrounding the brainstem is a reliable sign of a grave prognosis in brainstem injury. Contrast enhancement is useful in demonstrating whether the dural sinuses are displaced, thus differentiating EDH from SDH. Except in the rare case of vascular injury unassociated with EDH, CT correlated with the neurological examination is an accurate method of determining the nature, location, and extent of significant posterior fossa injury. Scans of high quality are mandatory, and frequent supplementary contrast studies are recommended.

CT of brainstem injury.

Cranial computed tomography (CT) scans of 1,600 head trauma patients, 67 of which demonstrated evidence of brainstem injury, were reviewed. CT diagnosis of brainstem injury was based on direct and indirect evidence. Direct signs, which include focal hemorrhage, significant intraparenchymal contrast enhancement, hemorrhagic contusion, and edema of the brainstem, appear as areas of high density, mixed density, and low density on the CT scan. Indirect signs are obliteration of the pontine, cerebellopontine angle, and perimesencephalic cisterns. Mortality and morbidity rates after brainstem injury are 2-3 times greater than for head trauma with descending transtentorial herniation, but without brainstem injury.

The contrast-enhanced CT scan in the diagnosis of isodense subdural hematoma.

The authors review 29 cases of surgically-proven isodense subdural hematomas examined by non-contrast and contrast-enhanced computerized tomography scans. Three types of isodense collections were noted: homogeneous isodense collections, mixed-density collections, and gravitational layering within subdural collections. Contrast enhancement within the cerebral cortex, cortical vessels, and subdural membranes led to the correct diagnosis in each case. Contrast-enhanced scans are essential for the evaluation of isodense subdural hematomas.

Diagnostic and prognostic implications of computed tomography of head trauma.

A total of 210 cases of head trauma were examined using noncontrast enhanced and contrast enhanced computed tomography scans. Evidence of contrast enhancement was seen in 97 cases (46%). Subdural hematoma and focal contusion were the most frequent entities demonstrating contrast enhancement. This finding was also frequently seen in patients with intraventricular hemorrhage (IVH) (5 of 17). Every one of the five patients in this series with IVH whose scans showed enhancement died, whereas out of the 12 whose scans showed no enhancement, five survived. Illustrative cases are presented. The authors feel that contrast enhanced scans are valuable in the evaluation of the full extent of head trauma.

Further experience with contrast-enhanced CT in head trauma.

Abnormal contrast enhancement was seen in 196 (39.8%) of 492 CT scans performed on patients for evaluation of head trauma. It proved most helpful in the diagnosis of isodense subdural hematomas and contusions. The advantages of contrast-enhanced CT scans in the evaluation of head trauma more than compensate for the additional time in performing the examination.

Effect of renal vasodilatation on the distribution of cortical blood flow in the kidney of the dog.

Studies were performed to evaluate the validity of using the radioactive microsphere technique to measure regional blood flow in the renal cortex. A technique was developed in which the renal cortex was divided into four equal zones, and the fractional and absolute distribution of blood flow in these zones was determined. It was consistently found that approximately 70% of the renal blood flow was distributed to the two outer cortical zones with the remaining 30% going to the two inner cortical zones. In addition, there was a reproducible pattern of distribution of blood flow in different areas of the same kidney after a single injection of microspheres and in the same area of the kidney after multiple injections of microspheres. Using this method, the distribution of renal blood flow was determined before and during the intrarenal administration of either acetylcholine (40 mug/min) or bradykinin (5 mug/min). Both agents decreased the per cent of blood flow to outer cortical zone 1, caused no change in zone 2, and increased the fractional blood flow in inner cortical zones 3 and 4. When this data was evaluated in terms of total blood flow, there was no change in zone 1, an increase in zone 2 commensurate with the change in total blood flow, and a marked increase in inner cortical zones 3 and 4 which accounted for 60 and 65% of the increase in total blood flow during acetylcholine and bradykinin administration, respectively.Therefore, the natriuresis of renal vasodilatation is associated with a redistribution to inner cortical nephrons.