Esophageal fistula sealing: choice of stent, practical management, and cost.

BACKGROUND: Three models of covered metal stents are available to seal esophageal fistulas. METHODS: Stainless steel covered stents were inserted in 5 patients (group I); nitinol covered stents were inserted in 12 patients (group II) with malignant (n = 14) or benign (n = 3) esophageal fistulas. RESULTS: Stent positioning was satisfactory in all cases. Fistula sealing was complete in 1 of 5 (20%) and 12 of 12 (100%) patients of groups I and II, respectively (p < 0.005). Continued esophageal leakage was initially related to the passage of fluids alongside the stent covering (n = 3) and to early stent migration (n = 1). Complications related to stent placement were observed in 2 of 17 (12%) patients and were fatal. During follow-up (mean 153 +/- 143 days), esophageal fistulas relapsed after initial sealing in 5 of 13 (38%) patients. Further treatment (glue or fibrin sealant injection, additional stent insertion) was attempted in 7 cases of persistent or relapsing esophageal fistula, with sealing obtained in 5 of them. The costs per patient and per day free from symptoms due to the esophageal fistula were $106 and $57 in groups I and II, respectively. CONCLUSION: Nitinol covered stents more frequently provided complete esophageal fistula sealing, as compared with stainless steel covered stents. Further treatments tailored to the mechanisms of fistula persistence or relapse often provided sealing.

Role of the double-contrast barium enema in rectal stenosis due to suppositories containing paracetamol and acetylsalicylic acid.

Self-treatment of chronic headache with suppositories containing paracetamol and acetylsalicylic acid may lead to serious complications. We report the radiological features of five cases of rectal stenosis following the use of such suppositories. The role of the double-contrast barium enema in suggesting the diagnosis of this complication of a chronic and often unrecognized self-treatment is emphasized.

Delayed enhancement of the bowel wall: a new CT sign of small bowel strangulation.

PURPOSE: To report a new CT sign of small bowel strangulation. MATERIALS AND METHODS: Two cases of small bowel obstruction evaluated by spiral CT with intravenous contrast injection. RESULTS: In both cases we observed an absence of parietal enhancement of the diseased bowel loop, visible on early scans only. This feature was accompanied by signs of bowel obstruction. The two patients had a segment of necrotic ileum resected. CONCLUSION: Delayed enhancement of a bowel loop in cases of small bowel obstruction should suggest the diagnosis of strangulation and lead to rapid surgical treatment.

[Spiral tomodensitometry of pancreatic calcifications]. / Tomodensitométrie helicoïdale des calcifications pancréatiques.

Chronic pancreatitis is characterized by the formation of intraductal precipitates that may later grow and calcify, forming large stones. These calcified stones, representing almost all the calcifications visible in chronic pancreatitis, are located in the major pancreatic duct or in the secondary branches. During the past 10 years, new sophisticated endoscopic techniques have been developed to remove obstructing calculi from the main pancreatic duct. These techniques require an accurate evaluation of the location of the calculi, since calculi cannot be removed from secondary branches. Therefore, a new radiological approach has been developed, based on helicoidal scanning and multiplanar and tridimensional reconstructions of the calculi layout.

Paradoxical contraction of pelvic floor muscles: clinical significance.

Paradoxical contraction of pelvic floor muscles during defecation straining has been said to be a cause of constipation and difficulty in passing feces. Nevertheless, controversies about its clinical significance still remained. Twenty patients with constipation and electromyographic evidence of paradoxical contraction of both puborectalis and external anal sphincter were investigated. An anorectal manometry performed in 17 confirmed the paradoxical contraction in 13 (76%). Electromyography revealed neurogenic signs in 11. Defecography demonstrated the paradoxical contraction in 6 only, but, together with barium enema and colon transit time, showed associated anorectal disorders in 9 patients. Twenty control patients were also studied. None had difficulty defecating. Nevertheless, 8 of them (40%) had paradoxical contraction. These observations suggest that paradoxical contraction of pelvic floor muscles may by asymptomatic and that another cause of emptying difficulties has always to be looked for.

[Encysted gossypiboma of the lesser omentum: complementary aspects of echography and computerized tomography]. / Gossypibome enkysté du petit épiploon: complémentarité de l'échographie et de la tomodensitométrie computérisée.

The authors report the fortuitous demonstration of an asymptomatic gossypiboma during the preoperative staging of a rectal carcinoma 13 years after abdominal surgery for perforated gastric ulcer. Ultrasonography disclosed a well-defined hypoechoic mass containing highly echogenic foci with a strong posterior shadow. The CT findings are reported, as well as the complementary aspects of sonography. Differential diagnosis from tumors of the lesser omentum is also presented.

Perinatal renal vein thrombosis. Sonographic demonstration.

The use of ultrasound (US) in the diagnosis of renal vein thrombosis (RVT) remains ill defined because the classical features lack specificity. The authors report three cases of renal vein thrombosis with a common US pattern: hyperechoic streaks in the interlobulary spaces confirming previous reports with the same pattern. The pattern has been observed in neonates as well as in utero. Associated vena cava thrombosis was present in two cases. This sign might be a specific sign of RVT.

Gd-DTPA-enhanced MR imaging of spinal tumors.

Forty-eight Gd-DTPA-enhanced MR examinations of the spine were performed in 40 patients referred for MR because of clinically suspected spinal tumor or for further evaluation of an expanded cord. The study group consisted of 32 patients with spinal tumors (seven ependymomas; seven astrocytomas; four hemangioblastomas; two arteriovenous malformations; two unidentified intramedullary neoplasms; four meningiomas; and single cases of metastatic breast carcinoma, cavernous hemangioma with associated hematomyelia, neurinoma, angiolipoma, drop metastasis from medulloblastoma, and epidermoid with diastematomyelia). In the remaining eight patients, other diagnoses were established: thoracic disk herniation (two patients), lumbosacral meningocele (one), syringomyelia secondary to arachnoiditis (four), and expanded cord secondary to gliotic tissue (one). All but two diagnoses were proved histologically by biopsy, surgery, or autopsy; in the two patients with arteriovenous malformations, the definitive diagnosis was made by spinal angiography. Contrast enhancement occurred in 30 of the 32 spinal tumors, and Gd-DTPA-enhanced T1-weighted images proved helpful in defining and outlining intra- and extramedullary spinal neoplasms. All ependymomas and astrocytomas (including low-grade astrocytomas) enhanced. In meningiomas, an immediate and uniform contrast uptake was demonstrated. Additional advantages of Gd-DTPA MR include the differentiation of solid tumor components vs syrinx or cyst or pseudotumoral areas of cord expansion, and the differentiation of residual or recurrent tumor from scar tissue in postoperative patients. Our results suggest that IV-injected Gd-DTPA improves MR sensitivity and specificity in the evaluation of spinal lesions.

Nervous system manifestations and neuroradiologic findings in acquired immunodeficiency syndrome (AIDS).

We report a series of thirteen patients with nervous system complications out of a total of thirty AIDS patients admitted to our hospital over the last two years for which CT and/or MRI have been performed. Five were homosexual men and eight patients (5 men, 3 women) were of African origin (Zaïre and Rwanda) (n = 5) or had had sexual intercourse with the local African population (n = 3). The nervous system complications encountered included: toxoplasma gondii brain abscess (2 patients); cryptococcus neoformans meningitis + toxoplasmosis (1 patient); toxoplasmosis + lymphoma (2 patients); progressive multifocal leucoencephalopathy (1 patient); lymphocytic meningitis or encephalitis (3 patients); lymphoma (1 patient); polyradiculoneuritis (3 patients). Three of thirteen patients had multiple intracranial abnormalities: one had concomitant intraparenchymal toxoplasma abscess and cryptococcal meningitis; in one patient a lymphoma developed after the successful medical treatment of a toxoplasma abscess; conversely, one patient developed a toxoplasma abscess two years after mediastinal radiotherapy for a systemic non-Hodgkin lymphoma. In conclusion, in our experience, nervous system toxoplasmosis is the most frequent AIDS related CNS complication. Our series demonstrates the high frequency of a second neurological disease occurring either concomitantly or separately. In these cases, while CT may readily identify the intracranial abnormalities, it contributes little towards an etiological diagnosis. Finally, our series illustrates the importance of a central African endemic focus for AIDS.

Multicystic dysplastic kidney: natural history from in utero diagnosis and postnatal followup.

Based on our experience with 13 in utero diagnoses we report the changes that may occur in the ultrasonic appearance of a multicystic dysplastic kidney. Macrocysts appear obvious only in the early third trimester of pregnancy. After reaching a maximum size the cysts start to involute either in utero or after birth, which may lead to a small noncystic mass, the so-called aplastic kidney, or even to complete disappearance of the entire dysplastic kidney. The dysplastic kidney seems vulnerable to anoxia or infection, and necrosis may supervene. The multicystic dysplastic kidney is a progressive and changing disorder. If its radiological appearance is typical management may be conservative with ultrasonic monitoring. Nephrectomy should be done if there is any abnormal clinical or ultrasonic change.

Transitional cell papillary carcinoma of the bladder in a child.

We report a rare case of transitional cell papillary carcinoma of the bladder in a 10-year-old girl who had hematuria. The tumor was diagnosed and assessed through VCUG and ultrasound. The tumor protruded into the urethra during micturition and its mobility was observed by both diagnostic procedures.