Radiographic underestimation of small bowel stricturing Crohn's disease: a comparison with surgical findings.

BACKGROUND: The purpose of this study was to determine the accuracy of barium radiography compared with intraoperative evaluation with passage of a balloon catheter for assessment of stricturing Crohn's disease (CD). METHODS: After institutional review board approval, we retrospectively reviewed a tertiary inflammatory bowel disease center's consecutive records of surgical patients between 1998 and 2003 with small intestinal CD to compare the number of strictures found at surgery with those identified preoperatively by barium imaging. Age, gender, prior surgical procedures, and steroid usage were recorded. By decision of the surgeons, all patients were treated with an identical approach that utilized intraluminal sizing with passage of a balloon-tipped catheter. RESULTS: In 118 patients, 230 strictures were identified by barium examination; 365 strictures were identified using the balloon catheter technique. Barium examination overestimated or underestimated the number of strictures in 43 of 118 patients (36%). Overall, barium radiography was least accurate in patients with strictures amenable to strictureplasty. Prior surgery and multiple strictures identified preoperatively by barium studies were found to decrease the accuracy of the barium examination, but the decrease did not reach statistical significance. After successful surgery for stricturing small intestinal CD, more than 90% of patients can successfully be weaned from their steroids within 3 months. Failure to be able to wean from steroids may suggest a missed stricture. CONCLUSIONS: Our data suggest that careful exploration and intraoperative, intraluminal testing of intestinal patency identify additional strictures compared with barium radiographs in a significant number of patients with CD undergoing small bowel surgical intervention.

Cystic pancreatic neoplasms: observe or operate.

OBJECTIVE: The objectives of this analysis were to define the incidence, natural history, and predictors of neoplasia in pancreatic cysts to determine which patients can safely be observed and which should undergo an operation. SUMMARY BACKGROUND DATA: With advancements in imaging technology, cystic lesions of the pancreas are being detected with increased frequency. Many of these lesions are small and asymptomatic, but they may be associated with pancreatitis or have malignant potential. Therefore, the management of these patients is complex, and knowledge of pancreatic cyst natural history and predictors of neoplasia are important. METHODS: From January 1995 through December 2002, all radiologic, surgical, and pathology records were reviewed for the presence of pancreatic cysts. In determining natural history, only patients with 2 scans more than 1 month apart at our institution were included. Patients with a clinical history and laboratory evidence of pancreatitis and/or pathologic confirmation of a pseudocyst were excluded. Factors analyzed as potential predictors of neoplasia included age, gender, cyst size, and symptoms. Serous cystadenomas, solid and cystic papillary (Hamoudi) tumors, lymphoepithelial cysts and simple cysts were all benign, whereas mucinous cystic neoplasms, intraductal papillary mucinous neoplasm, cystic neuroendocrine tumors, and cystadenocarcinomas were considered to be premalignant or malignant. RESULTS: Among 24,039 CT or MR scans, 290 patients (1.2%) had pancreatic cysts, and 168 of these patients (0.7%) had no documentation of pancreatitis. Seventy-nine of these patients with 103 cysts had more than 1 scan with an average interval of 16 months. These cysts increased in size in 19%, did not change in 59% and decreased in 22% of patients. Forty-nine patients underwent surgery for 14 benign (serous cystadenomas = 10, Hamoudi = 2, lymphoepithelial = 1, simple = 1) 25 premalignant (mucinous cystic neoplasm =16, intraductal papillary mucinous neoplasm = 5, neuroendocrine tumors = 4), or 10 malignant (intraductal papillary mucinous neoplasm = 7, cystadenocarcinomas = 3) lesions. Gender and cyst size did not predict neoplasia. However, presence of symptoms predicted premalignant or malignant pathology (60% vs. 23%, P < 0.05), and age over 70 years was associated with malignancy (60% vs. 21%, P < 0.02). CONCLUSIONS: These data suggest that cystic pancreatic neoplasms 1) occur in 0.7% of patients, 2) increase in 19% over 16 months, and 3) are likely (60%) to be malignant in patients older than 70 years. Therefore, we recommend surgical excision for pancreatic cysts that are increasing under observation, symptomatic, or detected radiologically in fit older patients.

Case report: magnetic resonance imaging in the diagnosis of epidural abscess complicating perirectal fistulizing Crohn's disease.

Epidural abscess is a rare complication of fistulizing Crohn's disease (CD), potentially appearing as neurologic symptoms or back and leg pain. We report a case of a large epidural abscess resulting from uncontrolled fistulizing CD, which was rapidly defined using gadolinium-enhanced magnetic resonance imaging (MRI). Whenever caudal neurologic symptoms, back pain, and fever arise in CD patients, diagnostic MRI of the pelvis in addition to conventional computerized tomography should be considered to identify perirectal fistulization to the spine.

Case report: "Popcorn" dystrophic ileal calcification in a patient with Crohn's disease.

Small bowel calcification is a rare finding, often associated with chronic infection or small intestinal neoplasms. The authors report a patient who developed dystrophic ileal calcification in the setting of medically refractory Crohn's disease. The patient had longstanding, obstructive ileal Crohn's disease, treated with corticosteroids for a 10-year period. Diffuse terminal ileal calcification was evident on radiographic studies, including plain films as well as abdominal CT scan. The patient underwent successful resection of the diseased segment of small bowel and has done well over the ensuing 3-year period. Dystrophic calcification is a rare complication of long-standing chronic inflammation in Crohn's disease that may occur in the absence of adenocarcinoma or chronic infection.

Radiographic evaluation of complex dysphagic patients: comparison with videoendoscopic technique.

Swallowing is a highly coordinated sequence of physiologic events. Many disease processes affect the patient's ability to have a functional swallow. The traditional videofluoroscopic swallowing study is an effective and established method for evaluating these patients and is the current examination of choice. Videoendoscopic evaluation is a safe and affordable procedure that can be used in an outpatient or office setting. It can also be a complementary technique, allowing direct visualization of pharyngeal structures and aspiration. We discuss the use of both techniques.