Choledochoduodenal fistula in the setting of Crohn's disease.

Of all the spontaneous fistulas that occur between the extrahepatic biliary system and the intestine, a choledochoduodenal fistula is rarely seen. When it does occur, it is most often secondary to a perforated duodenal ulcer, choledocholithiasis, or cholelithiasis. It may also be seen following complications related to iatrogenic injury or tuberculosis. Generally, choledochoduodenal fistulas are asymptomatic, but may present with vague abdominal pain, fever, and other symptoms related to cholangitis. As a result, they can be difficult to diagnose clinically before imaging is obtained. We present a case of a 74 year old, asymptomatic, female with a past medical history significant for Crohn's disease who was found to have a choledochoduodenal fistula demonstrated on MRCP, possibly secondary to her underlying inflammatory bowel disease.

Influence of correction of ocular magnification on spectral-domain OCT retinal nerve fiber layer measurement variability and performance.

PURPOSE: To analyze the influence of ocular magnification on the peripapillary retinal nerve fiber layer (RNFL) thickness measurement and its performance as acquired with spectral-domain optical coherence tomography (SD-OCT). METHODS: Spectral domain OCT measurements from 108 normal eyes (59 subjects) and 72 glaucoma eyes (58 patients) were exported and custom software was used to correct RNFL measurements for ocular magnification. Retinal nerve fiber layer prediction limits in normal subjects, structure-function relationships, and RNFL performance for detection of glaucoma were compared before and after correction for ocular magnification (Bennett's formula). Association of disc area with cross-sectional RNFL area was explored. RESULTS: The median (interquartile range, [IQR]) visual field mean deviation and scaling factor were 0 (-0.85 to 0.73) dB and 0.96 (0.93-1.00) in normal eyes and -4.0 (-6.0 to -2.2) dB and 0.99 (0.95-1.03) in the glaucoma group (P < 0.001 and P = 0.003, respectively; average correction 3%). Correction for ocular magnification caused a reversal of the negative relationship between the cross-sectional RNFL area and axial length (slope = -0.022 mm(2)/mm, P = 0.015 vs. = 0.22 mm(2)/mm, P = 0.007). However, such correction did not change RNFL prediction limits (except in superior and nasal quadrants), improve global or regional structure-function relationships, or enhance the ability of RNFL measurements to discriminate glaucoma from normal eyes (P > 0.05). The cross-sectional RNFL area was not correlated with optic disc area (P = 0.325). CONCLUSIONS: Correction of RNFL measurements for ocular magnification did not improve prediction limits in normal subjects or enhance the performance of SD-OCT in this group of eyes in which the axial length did not deviate significantly from average values. The cross-sectional area of the RNFL was not related to the optic disc area.

Macular ganglion cell/inner plexiform layer measurements by spectral domain optical coherence tomography for detection of early glaucoma and comparison to retinal nerve fiber layer measurements.

PURPOSE: To evaluate the performance of ganglion cell layer/inner plexiform layer (GCL/IPL) measurements with spectral-domain optical coherence tomography (Cirrus HD-OCT) for detection of early glaucoma and to compare results to retinal nerve fiber layer (RNFL) measurements. DESIGN: Cross-sectional prospective diagnostic study. METHODS: We enrolled 99 subjects, including 59 eyes with glaucoma (47 subjects) (mean deviation >-6.0 dB) and 91 normal eyes (52 subjects). Patients underwent biometry and peripapillary and macular OCT imaging. Performance of the GCL/IPL and RNFL algorithms was evaluated with area under receiver operating characteristic curves (AUC), likelihood ratios, and sensitivities/specificities adjusting for covariates. Combination of best parameters was explored. RESULTS: Average (SD) mean deviation in the glaucoma group was -2.5 (1.9) dB. On multivariate analyses, age (P < 0.001) and axial length (P = 0.03) predicted GC/IPL measurements in normal subjects. No significant correlation was found between average or regional GC/IPL thickness and respective outer retina (OR) thickness measurements (P > 0.05). Average RNFL thickness performed better than average GCL/IPL measurements for detection of glaucoma (AUC = 0.964 vs 0.937; P = 0.04). The best regional measures from each algorithm (inferior quadrant RNFL vs minimum GCL/IPL) had comparable performances (P = 0.78). Entering the GC/IPL to OR ratio into prediction models did not enhance the performance of the GCL/IPL measures. Combining the best parameters from each algorithm improved detection of glaucoma (P = 0.04). CONCLUSIONS: Regional GCL/IPL measures derived from Cirrus HD-OCT performed as well as regional RNFL outcomes for detection of early glaucoma. Using the GC/IPL to OR ratio did not enhance the performance of GCL/IPL parameters. Combining the best measures from the 2 algorithms improved detection of glaucoma.