The postcholecystectomy syndrome: bile ducts as pain trigger zone.

Sixty-five non-icteric patients presumed to have the postcholecystectomy syndrome (PCS) were followed up for 4-13 years after their first endoscopic retrograde cholangiopancreatography (ERCP) examination, which gave normal findings. All patients, however, experienced severe pain on injection of only 1-2 ml of contrast medium over 5-10 sec into the common bile duct (CBD). Thirty-four of the 65 patients were found to have true PCS on long-term follow-up studies, whereas 31 of them had other diseases. A second ERCP also showed normal results, and the injection-related pain was preceded by an abnormal pressure rise in the CBD at manometry. The CBD acted like a pain trigger zone, and the pain reaction might be diagnostic in everyday clinical practice. In conclusion, ultrasonography is an adequate diagnostic method in non-obstructive PCS. Medical treatment is often successful. ERCP and interventional treatment should be reserved for patients with obstructive symptoms and for patients in whom all medical treatment has failed.

Endoscopic diagnosis of gastric ulcer. Evaluation of the benefits of endoscopic follow-up observation for malignancy.

Examinations at an endoscopy unit in 1976 gave diagnoses of gastric cancer in 31 patients, malignant lymphoma in 3 and new benign gastric ulcer in 223 patients. Correctness of diagnosis was judged to be verified following surgery, autopsy, clinical follow-up or five-year survival. All the malignant lesions were macroscopically and/or microscopically recognized at the first examination, except for one that was then considered to be a submucosal or extragastric tumour, but was correctly diagnosed at surgery prompted by the endoscopic findings. Of the 223 benign ulcers, 219 received a correct diagnosis at the first examination. In the other four cases malignancy was macroscopically or microscopically suspected, but was excluded following surgical excision or repeat examination. Based on these data, the authors suggest that routine endoscopic follow-up of gastric ulcer to exclude malignancy is unnecessary if the primary examination has been performed by an experienced endoscopist, and if both the macroscopic and the microscopic (biopsy) judgement unreservedly are that the lesion is benign.

Effects of ioxaglic acid on cardiac functions during coronary arteriography in canines.

The new monoacid dimer ioxaglic acid (P286), The non-ionic metrizamide (Amipaque) and diatrizoate (Renografin 76) were compared regarding their effects on left ventricular pressure, the first derivative of left ventricular pressure, aortic pressures and on ECG changes during left and right coronary angiography in dogs. Ioxaglate was found to affect most of these parameters less than diatrizoate probably due to its lower osmolality. Ioxaglate should be regarded suitable for coronary angiography. However, ioxaglate was found to have greater effects on the cardiac function than the equiosmolar metrizamide. This is probably due to the chemotoxicity of the anion or possibly to the sodium content of the ioxaglic acid solution.

Coronary arteriography in canines with calcium-enriched ioxaglate and diatrizoate.

Ioxaglate, diatrizoate, and calcium-enriched solutions of these contrast agents were compared as to their effects on left ventricular pressure, the first derivative of this pressure, left ventricular stroke volume, stroke work, and mean aortic pressure during left coronary arteriography in dogs. Ioxaglate reduced these parameters significantly less than did diatrizoate. The calcium addition ameliorated the toxic effects of both ioxaglate and diatrizoate. There was an initial reduction of stroke work during and following the contrast injections, after which increased stroke work was observed. The calcium ions did not produce further augmentation of this increased stroke work.

Investigation of the effects of new contrast media on myocardial function.

When metrizamide was introduced by Almén and later dimerized media were synthesized, they offered the possibilities of studying the effects of contrast media with equal iodine content but different osmolalities. This article will describe findings regarding the cardiac effects of the nonionic medium, metrizamide, and of a monoacid dimer (P-286) in comparison to conventional ionic media. In assessing the toxicity of contrast media on the heart, it has been useful to separately evaluate the effects on the mechanical functions of the heart and on the electrical processes of the heart. Other parameters, such as the effects on coronary blood flow and effects on enzymatic processes, may be assessed, but so far they seem less interesting in terms of describing toxicity. We have excellent physiologic methods to measure the effects of contrast media on the heart's mechanical functions, but the new contrast agents have negligible effects on these functions. The side effects of these new media on the electrical processes of the heart are probably less negligible, but our methods of assessing them are less satisfactory. Change in heart rate and various ECG changes can be recorded, but their correlation to the arrhythmogenic activity is uncertain. Recently, preliminary results have been reported concerning the effects of contrast media on the fibrillation threshold. This index may be a new, important approach of finding ways to minimize cardiac side effects of contrast materials.

Cardiac function during left coronary arteriography in canines with ioxaglate, nonionic compounds, and diatrizoate.

The new contrast medium ioxaglate (P286) was compared with diatrizoate and the nonionic media metrizamide and C-29 regarding their effects on left ventricular pressure, the rate of rise in this pressure (dP/dt), stroke volume, peak aortic flow rate, and on the QT interval during left coronary arteriography in dogs. Ioxaglate and the nonionic compounds had significantly less effect on these parameters than diatrizoate. Contractility and QT time was least affected by the nonionic media, which have an osmolality similar to that of ioxaglate. This indicates that, in addition to osmolality, other properties of contrast solutions contribute to their toxic effects on the heart. Measuring contractility seems to be a more sensitive method in evaluating contrast media than measuring the performance of the heart as a pump.

The yield of endoscopy and double contrast radiography for the detection of early gastric cancer in Malmö.

To evaluate the efficacy of endoscopy and double contrast radiography for the diagnosis of early gastric cancer we compared two three-year materials of all gastric cancers detected in Malmö before and after these diagnostic tools were introduced. Despite a high diagnostic potential of these methods they have not significantly increased the detection of early gastric cancer in Malmö. Evidently the selection of the patients is unsatisfactory and modifications of the indications for these examinations are discussed.

Coronary angiography with iohexol and other contrast media in the dog. I. Electrocardiographic alterations.

In the dog the effects on ECG at coronary angiography with the non-ionic contrast media iohexol and metrizamide and the ionic medium diatrizoate were compared. Iohexol and metrizamide produced less prolongation of the PQ time during left-sided infusions and less prolongation of the QT time during right-sided infusions. Thus, as a cardiovascular contrast medium iohexol may cause fewer incidences of heart block and ventricular fibrillation than ionic contrast media.

Coronary angiography with iohexol and other contrast media in the dog. II. Left ventricular contractility and work.

At left coronary angiography in the dog the non-ionic media iohexol, 711 and metrizamide caused a similar reduction of the left ventricular pressure, stroke volume and work as Na/Ca/meglumine metrizoate but less than diatrizoate. After the initial reduction all media produced equal increase in the data, exceeding their preinjection levels. The calcium ameliorating the reduced cardiac function produced by metrizoate did not seem to impose an extra load on the left ventricle during the second phase.

Coronary angiography with iohexol and other contrast media in the dog. III. Contractility of the left ventricle.

Compared with the ionic contrast medium diatrizoate the new non-ionic media iohexol and 711 produced significantly less reduction of contractile force, left ventricular pressure and the first derivative of left ventricular pressure during left coronary angiography in the dog. These two media may be expected to have similar effects on the function of the myocardium as metrizamide.

ECG changes and arrhythmias induced by ionic and non-ionic contrast media during coronary arteriography in dogs.

Metrizamide (non-ionic, Nyegaard Co., Oslo, Norway), diatrizoate (ionic) and metrizoate (ionic) were selectively injected into the right or the left canine coronary artery. ECG was recorded and external defibrillation was performed whenever ventricular fibrillation occurred. During left coronary injections metrizamide prolonged the PQ and QT intervals less than did the diatrizoate. During right coronary injections metrizamide affected the QT interval less than either diatrizoate and metrizoate. During right coronary infusions metrizamide caused significantly fewer incidences of ventricular fibrillation than diatrizoate. In clinical coronary arteriography it is assumed that metrizamide would generate fewer AV blocks than diatrizoate and fewer incidences of ventricular fibrillation after right coronary injections than diatrizoate. Changes in the PQ and QT intervals during coronary arteriography can be used as tests to predict the safety of new contrast media.

Radiologic appearance of complete gastric erosions.

At gastroscopy of 656 patients, complete gastric erosions were found in 58 (11%). Radiography performed in 46 of these demonstrated erosions in 21 of 33 with a time span less than one month between radiography and gastroscopy but in only 4 of 13 with a time span of one to 3 months. Double contrast technique supplemented with films of compressed barium-filled antrum demonstrate the lesions best. Complete erosions have often appearances simulating gastric polyps or large mucosal folds and are often found together with ulcers.

Mechanism of production of cardiac conduction abnormalities due to coronary arteriography in dogs.

Left coronary arteriography and left coronary artery injections of Tyrode's solution and glucose solutions were performed in 12 anesthetized dogs. The contrast medium was found to prolong the conduction time through the AV junctional tissue and through the most distal part of the conduction network as verified by His-bundle electrogram and by surface ECG (lead II). The results indicate that for evaluation of the effects on conductivity of various media, it is most reliable to measure the altered conduction velocity in the AV nodal region. The prolongation of conduction time produced by contrast medium explains heart conduction blocks and may contribute to the genesis of ventricular fibrillation, frequent complications to coronary arteriography. The data suggest that anoxemia does not cause this delayed conduction. Hyperosmolarity contributes to the alterations of the conductivity, but the ionic composition and anion toxicity of the contrast medium also may be of importance.

Cardiac function during coronary arteriography with calcium enriched diatrizoate and metrizamide.

Calcium was added to diatrizoate (Renografin 76) and metrizamide (Amipaque) to concentrations from 2.5 to 50 mEq/1. The solutions were injected into the left coronary artery in dogs with either the chest opened or closed. In open chest experiments contractile force and aortic pressures were recorded. In closed chest dogs, left ventricular pressure, first derivative of that pressure and aortic pressure were registered. The calcium ion concentration was linearly, inversely related to the effect of the contrast solutions on the recorded parameters. In these experiments the optimal amount of calcium is suggested to 40 mEq/1 added to the diatrizoate solution but only 10 mEq/1 added to the metrizamide solution. No ECG changes due to calcium addition could be registered. The cardiac toxicity of these contrast media seem to be due to an interference with the calcium flux across the cell membrane. The effect on contractility can be recorded with the same reliability in either closed or open chest experiments.

Intravascular electrically induced thrombosis in the dog. Thrombus detection by ionic and nonionic contrast media.

Reliable, large, nonobstructive thrombi were produced by electrical stimulation of the wall of the inferior caval veins in dogs, thus avoiding surgical trauma or introduction of chemical substances. Metrizamide was found to adhere longer to the thrombi than an ionic medium (iothalamate) at comparable iodine concentrations. This may be due to the much higher viscosity of metrizamide.

Lymphoid hyperplasia of the colon in childhood.

A retrospective inspection of films from colon examinations revealed evidence of lymphoid hyperplasia in 24 of 229 infants and children. The condition is more frequently demonstrated at double contrast examination than with the conventional barium enema. Analysis of symptoms and signs and information obtained at follow-up suggests that this condition is usually, if not always, benign in childhood.

Coronary angiography with diatrizoate and metrizamide. Comparison of ionic and non-ionic contrast medium effect on coronary blood flow in dogs.

The non-ionic contrast medium metrizamide produced a smaller coronary flow increase than the ionic medium diatrizoate after injection into the main left coronary artery in dogs and had also a shorter transit time through the coronary vessels. The coronary veins were better filled with metrizamide. The reduced coronary flow effects of metrizamide compared to ionic contrast medium and the improved venous filling makes metrizamide a favorable contrast material for use in coronary angiography.

Addition of calcium or other cations and of oxygen to ionic and non-ionic contrast media. Effects on cardiac function during coronary arteriography.

Metrizamide is a new non-ionic water soluble contrast agent. Isolated rabbit hearts were perfused with solutions of 1) metrizamide, 2) metrizamide with plasma equivalent amounts of cations, 3) oxygenated metrizamide, 4) oxygenated metrizamide with cations, 5) diatrizoate. Solutions of 1) metrizamide, 2) metrizamide with plasmaequivalent amounts of cations, 3) metrizamide with calcium ions, 4) metrizoate (ionic medium) with calcium ions, metrizoate with 5) low and 6) high sodium content and 7) diatrizoate were injected into the left coronary artery of dog hearts in vivo. Maximal change of myocardial contractile force was measured with a strain gauge arch. Changes in aortic blood pressures were also recorded. In both sets of experiments metrizamede affected these parameters less than the ionic contrast media. The addition of calcium ions to both ionic and non-ionic media reduced the adverse effects on the observed cardiac funcitons, while simultaneous addition of plasma equivalent amounts of four cations as metrizoate salts had no beneficial effects. Sodium ions had in high concentration deleterious effects on cardiac performance. Oxygen saturation of the contrast medium had no observable effect. The adverse effects on cardiac mechanical function of sodium ions and possibly other cations contained in a contrast medium solution might be counterbalanced by the addition of calcium ions to the solution.