Comparison of the rating scale and the standard gamble in measuring patient preferences for outcomes of gallstone disease.

To estimate patient preferences for gallstone-related treatments and outcomes, and assess how preferences vary by patient characteristics and scaling technique, the authors randomly assigned 40 patients without gallstones to interviews based on a rating scale (n = 22) and a standard gamble (n = 18). The patients assigned preference values (possible values 0 to 1) to open cholecystectomy (mean 0.45 by rating scale, 0.78 by standard gamble), laparoscopic cholecystectomy (0.71, 0.91), extracorporeal shock-wave lithotripsy (0.77, 0.89), acute cholecystitis (0.36, 0.77), lifetime biliary colic (0.41, 0.71), postcholecystectomy syndrome (0.43, 0.79), asymptomatic stone necessitating treatment with bile acids (0.76, 0.96), and surgical scar (0.79, 0.998). Preferences varied little by age, gender, or race. Standard gamble values were highly correlated with, but significantly greater than, rating scale values. The authors conclude that patients' preferences for gallstone-related conditions generally are significantly less than one, and differ markedly by the scaling technique used to derive them. These results should be considered when patient preferences are incorporated into analyses of gallstone treatments.

Cost-effectiveness of extracorporeal shock-wave lithotripsy versus cholecystectomy for symptomatic gallstones.

To evaluate the cost-effectiveness of extracorporeal shock-wave lithotripsy vs. cholecystectomy for symptomatic gallstones, a model was constructed that projects charges and survival for both treatments. For a 45-year-old woman with one small stone, treatment with extracorporeal shock-wave lithotripsy rather than cholecystectomy is projected to result in an average gain of only 3 days of life and an average increase in direct medical charges of $1729 over 5 years of follow-up. The resulting marginal cost-effectiveness of extracorporeal shock-wave lithotripsy vs. cholecystectomy is $216,000 of extra charges per year of life gained with extracorporeal shock-wave lithotripsy. Extracorporeal shock-wave lithotripsy is projected to be much more cost-effective for elderly than for young patients (10-20-fold difference), but considerably less cost-effective for multiple stones than a single stone (2-4-fold difference), and less cost-effective for women than men (twofold difference). Adjusting for effects of morbidity on quality of life, extracorporeal shock-wave lithotripsy is projected to have slightly better quality-adjusted survival than cholecystectomy for the small subset of patients with one stone (by 8 to 43 days at 5 years) but not for young patients with multiple stones. It is concluded that decisions about appropriate use of extracorporeal shock-wave lithotripsy should consider the effects of patient characteristics on clinical and economic outcomes.

Computed tomographic evaluation of gallstone calcification for biliary lithotripsy.

As the Food and Drug Administration trials for biliary lithotripsy in the United States near completion, future criteria for patient eligibility remain to be defined. Gallstone calcification greater than 3-mm partial rim on plain film (KUB) or oral cholecystogram (OCG) has excluded patients thus far, since early results of gallstone clearance (lithotripsy plus chemodissolution) were suboptimal with calcified stones. To evaluate the usefulness of these criteria for gallstone fragmentation, computed tomographic (CT) scans were performed on 20 patients immediately prior to lithotripsy to evaluate gallstone density and 24 hours after lithotripsy to observe the CT appearance of fragmentation. The adequacy of fragmentation was determined by pre- and post-lithotripsy sonography. This report constitutes the results of these investigations.

CT of fluid collections associated with pancreatitis.

Fluid collections are an important component of severe pancreatitis because they may produce a detectable mass and may be responsible for prolongation of fever and pain. Among 59 cases of clinically verified pancreatitis, 32 were shown by CT to be complicated by pancreatic and/or extrapancreatic fluid collections. Pancreatic fluid collections, diagnosed in 16 patients, were typically on the anterior or anterolateral surface of the gland and were covered only by a thin layer of fibrous connective tissue. Extrapancreatic fluid collections were detected in the lesser sac (19 cases), anterior pararenal space (15), posterior pararenal space (six), in or around the left lobe of the liver (five), in the spleen (three), and in the mediastinum (one). The potential undesirable consequences of escape of pancreatic juice are necrosis, abscess formation, or prolonged inflammation of the peripancreatic tissues. Relative preservation of pancreatic integrity as observed by CT was regularly found in patients with large extrapancreatic fluid collections, suggesting that escape of pancreatic juice produces a beneficial decompression of the pancreatic duct system.

Esophageal hematoma associated with thrombocytopenia.

Esophageal hematoma secondary to thrombocytopenia has only recently been described in the literature in a single case report. This article presents the clinical manifestations and radiographic findings of 4 additional cases of esophageal hematoma secondary to thrombocytopenia. Three patients were receiving treatment for leukemia, and the other patient had aplastic anemia. Previously reported cases of esophageal hematomas from other causes are reviewed.

Localized tumor-like lesions in ulcerative colitis and Crohn's disease of the colon.

Ulcerative colitis and Crohn's disease of the colon may manifest roentgenographically as localized tumor-like lesions of the colon. Such lesions are often of inflammatory origin but are likely to be mistaken for polypoid carcinoma or infiltrating submucosal malignancy. Four patients with localized inflammatory lesions of the colon that mimicked a neoplastic process are reported. The clinical features and the radiological-pathological correlation of such lesions are presented.

Unusual manifestation of tuberculosis: TE fistula.

Fistulas between the tracheobronchial tree and the esophagus (TE fistula) caused by tuberculosis are rare; usually they are associated with readily apparent pulmonary and/or mediastinal infection, and require surgical management. The patient we describe presented with a TE fistula as the only manifestation of active tuberculosis. This case represents the first report of successful nonsurgical treatment of tuberculous TE fistulas.