Gastrointest Radiol 2, 175-178 (I977) Gastrointestinal Radiology ~'~ by Springer-Verlag 1977

Abstracts of Selected Papers fi'om the Current Literature

The Columnar-Lined Esophagus Analysis of 26 Cases. Robbins AH, Hermos JA, Schimmel EM. Friedlander DM, Messian RA: Radiology 123.'1 7, 1977 (Radiology Service. VA Hospital, 1505 Huntington Ave., Boston, MA 02130)

Twenty-six patients with biopsy proved columnar-lined esophagus were evaluated with respect to clinical, radiographic and en- doscopic findings. A clinical follow-up of 1 month to 4 years was available in 23 patients.

The most common clinical symptom was dysphagia (81 per cent). Heartburn and/or regurgitation was noted in 77 per cent of patients. Twenty-one of 26 patients had a hiatus hernia. Gastroe- sophageal reflux was seen in 16 patients. Esophageal ulcers in the area of columnar epithelium were radiographically identified in 14 patients and confirmed endoscopically in 9. Twelve patients had an associated esophageal stricture. One patient had adenocarci- noma in an area of Barrett's esophagus. Manometric studies showed a lower than normal lower esophageal sphincter pressure in i6 of 17 patients.

The data supports the hypothesis that Barrett's esophagus is an acquired replacement of squamous epithelium with non-parietal cell columnar epithelium secondary to reflux esophagitis.

Jeanne W. Baer, MD

Early Esophageal Cancer: Definition, Pathology, Present Status and Prognosis (In Japanese). Nabeya K, Takigawa H, Ri S: Stomach and Intestine 11:285 292, 1976 (Department of Surgery, School of Medicine, Kyorin University. Mitaka-City, Tokyo, Japan)

Early esophageal carcinoma is defined as a carcinoma of the eso- phagus which is limited to the mucosa and submucosa without metastases. On the basis of this definition, the authors have collected 58 proven cases of early esophageal carcinoma in Japan up to November 1975.

The symptoms presented by the patients were minimal and vague. In most of the cases the diagnosis was established less than 2 months from the appearance of the initial symptoms. A correct diagnosis is most effectively made by the combination of radiology, endoscopy, biopsy and cytology. The raised type of carcinoma is easily diagnosed while the superficial, spreading type is the most difficult to detect.

Macroscopic observation of the resected specimens revealed that most of early esophageal carcinomas were of the elevated type with well-defined margins. In a few cases of the fiat type it was difficult to assess the limits of the carcinoma. In 55% of

the cases the lesions were less than 30mm in diameter and in 6 less than 10 mm in diameter.

Histologically, well differentiated squamous cell carcinomas were demonstrated in 90% of the cases, adenocarcinoma in 4, and carcinosarcoma in 3. The process of tumoral invasion was confined to the mucosa in 16% of the cases, to the muscularis mucosae in 5% and to the submucosa in 79%.

The senior author advances the hypothesis that the growth of early esophageal carcinomas can be divided into 3 stages: initial minute type (micro-type). intracavity extending type and, intramu- rally spreading type.

The diagnosis and treatment of early esophageal carcinoma results in an excellent prognosis: however, it is admitted that its early detection remains difficult.

Joe Ariyama, MID

Inflamed Duodenal Diverticulum. Preoperative Radiographic Diag- nosis. Beachley MC, Lankau CA Jr: Am J Dig Dis' 22.'149 154, 1977 (Department of Radiology, Medical College of Virginia, MCV Station, Box 728. Richmond, VA 23298)

The sixth reported case of duodenal diverticulitis diagnosed preoper- atively is presented. This 68-year-old male was admitted with chills, fever, upper abdominal pain, leukocytosis and elevated serum amy- lase. The radiograph of the abdomen revealed a mottled circumlinear collection of gas in the region of descending duodenum correspond- ing to the location of a large paravaterian diverticulum. An upper gastrointestinal series with water-soluble contrast media, and the subsequent laparotomy confirmed the presence of an inflamed diverticulum extending behind the head of the pancreas and asso- ciated with acute pancreatitis and focal fat necrosis.

The duodenum is second only to the colon in frequency of diverticula formation but only 1-10% of these diverticula may present with any symptoms. Those arising from the lateral border of the duodenum are more likely to undergo torsion and develop acute diverticulitis with perforation. The latter findings may be manifested by the presence of a mottled immobile collection of gas in the paraduodenal region resembling emphysematous chole- cystitis or retroperitoneal emphysema. As in the herein reported case the preoperative consideration of an inflamed duodenal diver- ticulum located within or behind the head of pancreas is important since the lesion may be easily overlooked at surgery in the presence of pancreatitis with usually accompanies this condition.

Gary G, Ghahremani, MD

176 A bst facts

Radiologic Examination of the Small Intestine by Double Contrast (Examen radiologique de l'intenstine grOle en double contraste). Clement J-P, Burelle H, Corbeau A, Colleter JF: J Radiol Eh, ctrol 58231-236 , 1977 (Service Central de Radiologie, H6pital Sainte- Marguerite, 270, Boulevard Sainte-Marguerite, F-13009 Marseille, France)

The authors report on the results obtained in 170 examinat ions of the small bowel performed by the double contrast technique.

The procedure consists of duodenal intubation with a Dotter- Bilbao Tube (its tip having been positioned at the level of the duodenal-jejunal junction) and on the introduction in one bolus of 100 cc of micropaque slightly diluted, and then of 100 cc more in the amoun t of 10 cc per bolus.

When there is satisfactory opacification of the jejunal loops their morphology and motility are thoroughly analyzed under fluo- roscopy and by positioning the patient in the supine and prone postions. When the contrast medium reaches the terminal ileal coil, 300 cc of air are introduced, and then, more is introduced in fracfions of about 100 cc up 1o a limit of 700 to 1000 cc. The progression of the air is followed under fluoroscopy and evaluation of the appearance, motility, and dissociation of the loops is made by positioning the patient in several projections, including the Tren- delcnburg position. Overhead films are taken with and without air contrast. The examination lasts about two hours.

The results obtained were reviewed by three observers and the conclusions reached were the following: 1) the double contrast examinat ion improved the demonst ra t ion of the mucosal folds and allowed a better evaluation of the transit of the contrast medium through the je junum. The dissociation of the loops of the je junum was not improved. 2) In the ileum, the mucosal studies by the double contrast method were superior to the classical procedure and markedly improved also was the dissociation of the various loops of ileum. 3) In 27 cases organic lesions were demonstra ted ranging from malignancy (5 cases), Crohn ' s disease, multiple diver- ticula and follicular ileitis (4 cases each), Meckel diverticulum (3), ischemia (2), and different phatologic processes in the remaining 5 cases. In 12 cases " func t iona l " changes were demonstrated.

Antonio F. Govoni, M D

lschemia of the Small Intestine. Marshak RH, Lindner AE, Mak- lansky D : A m ,! Gastroenterol 66 ." 390 400, 1976 (Mt. Sinai School of Medicine, 5th Ave. and 100 Str., New York, NY 10029)

Reported are 5 cases of ischemia of the small intestine. The age of the patients ranged between 55 and 82 years and all patients were males. Four patients presented with history of pain, diarrhea and bloody stools. In the fifth patient no diarrhea or hematochezia were present.

The roentgen findings were similar to the pattern noted in ischemia of the colon. Rigidity of a segment of a loop with spasms, separation of loops of small bowel, area of stricture and blunting of the folds were the usual roentgen findings. Repeat studies at a later date showed return to normal findings in 4 individuals. In the fifth patient a moderate narrowing of the distal loops of ileum with rigidity which was seen in the first examinat ion remained unchanged in a follow-up study performed 30 months later, even though the patient had 11o abdominal complaints.

It is pointed out that in many cases a process of fibrosis may occur resulting in a narrowed segment of small bowel and also in the formation of pseudo diverticula. These s~rictures are appar- ently a more frequent complication than in the colon.

In the differential diagnosis regional enteritis and lymphosar- coma should be considered.

The article is accompanied by numerous and clear illustrations.

Antonio F. Govoni, M D

Yersinia Enteritis and Enterocolitis-Gastrointestinal Aspects. Van Trappen G, Agg HO, Ponette E, Geboes K, Bertrand P: Gastroen- terologr 72220-227 , 1977 (Department of Medicine, Akademisch Ziekenhuis St. Rafael, B-3000 Leuven, Belgium)

Yersinia enterocolitica is a gram negative rod resembling non- lactose fermenting escherichia coli, which recently has been rec- ognized to produce enteritis with fever and diarrhea. This is a report of 37 adult patients seen with this entity.

Radiographic studies on 24 patients showed involvement of the terminal ileum in 21 cases. The findings were those of a coarse, irregular or nodular mucosal pattern usually associated with ulcer-

ations. The ulcers varied from aphthoid ulcers (tiny barium collec- tions surrounded by an edematous halo) to round or oval ulcers 5 to 7 mm in diameter, to longitudinal ulcers about 2 cm in length.

Although treatment with tetracycline o1" chloramphenicol resulted m the disappearance of most of the symptoms and signs in 4 to 6 weeks, the radiographic picture of nurnerous small filling defects in the terminal ileum (follicular ileitis) persisled for months. There was no evidence that yersinia enterocoIitica infections ever resulted in Crohn ' s disease.

David Bryk, MD

Pathogenesis of Massively Bleeding Colonic Divert iculosis-New Observation. Meyers MA, Alonso DR, Baer JW: A m J Roentgenol Radium Ther Nucl M e d 127.'90l 908, 1976 (Department of Radiol- ogy, New York Hosp i t a l -Corne l l Medical Center, New York, NY t002I )

The authors report on the arteriographic, microangiographic and histologic findings observed in ten cases of massively bleeding colo- nic diverticulosis.

The changes noted were: 1) asymmetric rupture of the vas rectum toward the lumen of the diverticulum precisely at its dome or antimesenteric margin, 2) conspicuous eccentric intimal thicken- ing of the vas rectum often with medial thinning and duplication of the internal elastic lamina at or near the bleeding point and 3) general absence of diverticulitis.

The precise bleeding site was documented histologically in eight of the ten cases. The sites of arterial hemorrhage were basically related to the distinctive angioarchitecture of the colonic diverticu- lum.

The sequence of events proposed as the pathogenesis of bleeding colonic diverticulosis is as follows injurious factors, the nature of which is yet to be determined, arising within the colonic or the diverticular lumen produce eccentric damage to the luminal side of the underlying vas rectum. The artery reacts with eccentric intimal thickening and following persistent or recurrent damage, the intimal thickening may become concentric but retains accentua- tion towards the lumen of the diverticulum. Consequently, progres- sive segmental weakening of the arterial wall leads to eccentric rupture and hemorrhage. The increased frequency of bleeding in right sided diverticula may be explained by the fact that the diverti- cula arising in the right colon have wider necks and domes. As a result, their vasa recta are exposed over a greater length to injurious factors arising from the colon.

David Bryk. MD

On the Nature and Etiology of Vascular Ectasias of the Colon. Boley S J, Sammar tano R, Adams A, DiBiase A, Kleinhaus S. Sprayregen S: Gastroenterologr 72.'650 660, 1977 (Department of Surgery, Montefiore Hospital and Medical Center, 111 East 210 Street, New York, NY 10467)

Abstracts 177

In this study, specimens of the right colon were examined by injec- tion of silicone rubber compound into the vessels, followed by clearing of the specimen. Some specimens were examined only by histological sections. In the first part of the study, 19 right colons were studied from patients with clinical and angiographic diagnoses of cecal vascular lesions. In the second part of the study, 15 colons were examined that had been resected for carcinoma in patients who had no history of bleeding.

In the injected specimens taken from patients with clinical and angiographic diagnoses of cecal vascular lesions, all the specimens showed one or more mucosal vascular ectasias. These were second- ary to dilated tor tuous submucosal veins which were the most prominent feature, and were often present without mucosal ectasia. In the 15 specimens studied following resection for carcinoma, 4 mucosal ectasias were found and 8 submucosal ectasias.

The authors contend that with muscular contraction or in- creased intraluminal pressure, the vein perforating the muscular layers of the bowel is partially obstructed. After repeated episodes over many years, the submucosal vein and venule draining into it become dilated and tortuous. Later the capillary ring becomes similarly involved as ectasia of the venules progresses. Ultimately, as the capillary ring becomes dilated, the precapillary sphincter becomes incompetent and a small arteriovenous communicat ion is present through the ectasia. This study further suggests that these lesions are: 1) vascular ectasias developing as a degenerative process of aging, 2) are present with or without bleeding in a significant proportion of the population over 60, 3) are multiple more often than single and 4) may represent the most common cause of major lower intestinal bleeding in the elderly.

David Bryk, M D

The Role of Colonoscnpy in the Differential Diagnosis of Inflamma- tory Bowel Disease. Waye JD: Gastrointest Endosc 23.'150 154, 1977 (1065 Park Ave., New York, NY 10028)

The author on the basis of a very large series of colonoscopies and biopsies of the colon presents definitive colonoscopic criteria which have proved to be of practical importance in the differential diagnosis between ulcerative and granulomatous colitis.

Analyzed in details are 10 points describing the colonoscopic findings in ulcerative colitis: 1) rectal involvement; 2) erythema; 3) granulosity; 4) friability; 5) edema; 6) ulcerations; 7) bridging; 8) pseudopolyps; 9) contiguity; and, 10) carcinoma.

Ten other points are analyzed and discussed in describing the colonoscopic findings in granulomotous colitis: 1) normal rectum; 2) asymmetry of involvement; 3) cobblestoning; 4) normal vascula- ture; 5 ) edema ; 6) ulcerations in normal mucosa ; 7) serpiginous ulcers; 8) pseudopolyps; 9) skip-areas; and, 10) amyloidosis.

Reviewed also is the problem of a dysfunction of the ileostomy stoma and the role of colonoscopy in the insepction of the stoma.

In the conclusions it is emphasized that colonoscopy should not be performed in all patients presenting with an inf lammatory bowel disease, but should be used in those patients who present a specific problem. The most important situations calling for this procedure should be the evaluation of a stricture, of pseudopolyps, their differentiation from a carc inomatous lesion, and the preopera- tive evaluation of a granulomatous colitis.

Antonio F. Govoni, M D

Angiographic Abnormalities in Partial Budd-Chiari Syndrome. Ma- guire R, Doppman JL: Radiology 122:629-635, 1977 (Bldg. 10, Room 6S211, National Institute of Health, Bethesda, M D 20014)

Partial occlusion of hepatic veins results in the arteriographic ap- pearance of tortuous, crowded arteries in the shrunken, venooc-

eluded hepatic lobe, occasionally associated with retrograde portal flow. Stretched and separated arteries are visualized in the unoc- eluded hepatic lobe due to increased perfusion. A "spider web" network of vessels is seen when a patent hepatic vein is injected with contrast material.

In order to explain the nature of this network of vessels, occlu- sion of 2 or 3 hepatic veins was carried out in 8 monkeys. Subse- quent arteriography and venography were performed which confirmed the findings observed in patients with partial occlusion of hepatic veins. The "spider web" network of vessels proved to be collateral flow from the patent hepatic veins to veins within an obstructed lobe and then back to an unobstructed vein.

Jeanne W. Baer, MD

Ultrasonic and Radiographic Cholecystography. Bartrum RJ Jr, Crow HC, Foote SR: N Engl J Med 296.538 541, 1977 (Depart- ment of Radiology, Dar tmouth Medical School, Hanover, NH 03755)

In this study an at tempt was made to define the relative merits of radiographic and ultrasonic cholecystography. For this purpose, 208 randomly selected patients with possible cholelithiasis were studied. In each of these patients ultrasonic cholecystography was performed and interpreted before radiologic cholecystography. The overall accuracy of the ultrasonic examinat ion was 93%, with a false-negative rate of 11% and an indeterminate rate of 4%. In patients whose gallbladders visualized on single dose oral cholecys- tography the result of the radiographic study was considered the true or final diagnosis. Those whose gallbladder status remained indeterminate underwent subsequent cholecystectomy. In this series, the indeterminate rate for oral cholecystography using a single dose was 24%, while it was 8% for the double dose study.

The authors conclude that both examinat ions are useful in evaluating patients for possible cholelithiasis. Single dose oral cho- lecystography seems to be the procedure of choice for initial exami- nation of the gallbladder. If the gallbladder status is indeterminate on this examination, the authors recommend an immediate ultraso- nic cholecystogram, which will permit a diagnosis to be made with a single visit in the majority of cases.

David Bryk, M D

The Use of Ultrasound in the Diagnosis of Hydatid Cysts of the Liver. A Study of 31 Cases (Valor de Ins ultrasonidos en el diagn6s- tico de los quisted hiatidicos hep~ticos. Estudio de 31 casos). De Dins- Vega JF, Muro J, Perez-Jimenez F, Segura JM, Ortiz Vasquez O: Rer Clin Esp. 144:3742, 1977 (Ciudad Sanitaria de la Seguridad Social " L a Paz" , Madrid, Spain)

Ul t rasound provides a reliable non-invasive means of diagnostic evaluation of the liver for hydatic cysts. Thirtyone of 35 appar- ently positive cases were proven to be correctly diagnosed, usually with surgical confirmation. Almost all of the true positive cases showed smooth sonolucent zones, up to 3 in number , which re- mained sonolucent with high gain. The two cysts which showed small internal echos with high gain were proved to be superinfected hydratid cysts.

The 4 false positive findings were produced by: 1) a cyst of the anterior rectus muscle; 2) an echo-free zone from a costal cartilage arch in a malnourished patient; 3) interposition of a fluid-filled colon loop; and, 4) a very dilated gall bladder.

Alan E. Oestreich, M D

178 Abstracts

Follow-up of Patients with Portal Hypertension and Esophageal Varices Treated with Percutaneous Obliteration of Gastric Coronary Vein. Lundcrquist A, Semert G, Ty~en U, Vang J: Radiology 122:59 64, 1977 (Department of Diagnostic Radiology, University Hospital, S-22185 Lund, Sweden

A group of 21 patients with cirrhosis, portal hypertension and esophageal varices were treated with percutaneous transhepatic catheter embolization of the coronary and/or short gastric veins with a combinat ion of thrombin, gelfoam and/or Etolein.

The procedure was successfully performed and angiographically documented in 12 patients. In 5 patients with octual bleeding the obliteration was successful in 3. In 8 patients an hemorrhage reoccurred within 2 mon ths of the procedure, in 2 cases from gastric ulcers. Six patients died within 14 months of the preocedure; 3 of whom had a t h rombus in the portal vein.

Twelve patients were re-examined angiographically to deter- mine the sequelae of the thrombosed coronary vein. Recanalization occurred in 10 patients necessitating a second embolization. Six of these patients died 1 week to 2 mon ths following the second procedure.

The major cause of death was hepatic coma in 8/12 patients, six of whom belonged to the C group of Child 's classification.

Jeanne W. Baer, M D

The Diagnosis of Pancreatic cyst by Endoscopic Retrograde Pancrea- tography and Ultrasonic Scanning. Andersen BN, Hancke S, Nielsen SAD, Schmidt A: Ann Surg 185:286-289, 1977 (Kommunehosp i - talet, 1. Afdeling, Oster Far imagsgade 5, DK-1399 Copenhagen, Denmark)

Fourteen patients with verified pancreatic cysts were examined by both preoperative endoscopic retrograde pancreatography (ERP) and ultrasonic scanning. ERP showed filling of a cyst in 4 patients and raised suspicion of a cyst in 8. in two patients it was not possible to visualize the pancreatic duct. Ultrasonic scanning showed a cyst in 12 patients. There were two false negative ultrasonic diagnoses. These two were correctly diagnosed by ERP. Ultrasonically guided percutaneous puncture was carried out on 19 occasions in 8 patients. Cysts down to 2 cm in diameter were punctured without difficulty. There were no clinically significant complications due to the punctures. One patients was followed for 20 months without ultrasonically demonstrable recurrence of a large cyst aspirated, showing that definite therapy is possible by this method. Puncture can be used to verify" the diagnosis and as treatment in patients where surgery is contraindicated.

Authors" Summary

Endoscopic Sphintero-Papillotomy, A Comparison with Surgical Sphintero-Papilloplasty (In Japanese). Sohma T, Tatekawa I, Saito S, Ono M, Fijuita R: Stomach and Intestine 11. 1405-1415, 1976 (Depar tment of Surgery, School of Medicine, Kyorin University, Mitaka-City, Tokyo~ Japan)

Electric incision of the ampulla of Vater using a fiberduodenoscope was performed in 41 subjects including 39 cases of choledocoli- thiasis and 2 cases of benign papillary stenosis. The surgical instru- ment was specifically devised by the authors.

The common bile duct stones were successfully removed in 34 out of 39 cases. The smaller calculi were passed spontaneously and a basket catheter was used for the removal of the larger stones.

In cases with benign papillary stenosis sufficient bile drainage was obtained and jaundice disappeared.

No critical complications were encountered and there was no post-operative infection or liver function disturbance.

Direct observation of the lumen of the biliary tree was obtained by introducing a small fiberscope through the fiberduodenoscope passed through the incised ampulla. This procedure allows the detection of small residual stones and malignancy of the bile duct.

The effectiveness of endoscopic sphintero-papil lotomy is not inferior to that of surgical sphintero-plasty. This method can be successfully used in patients with poor surgical risk. However, the procedure should be performed by experienced hands.

Joe Ariyama, MD

Computerized Axial Tomography in the Diagnosis of Acute and Chronic Panereatitis (Axiale computer-gesteuerte Tomometrie bei akuter und chronischer Pankreatitis). Baert AL, Ponette E, Pringot J, Marchal G, Dardenne A, Coenen Y: Radiologe 17:18l 188, 1977 (Department of Radiology, University Hospital, Capucienen- voer 35, B-3000 Leuven, Belgium)

The authors between May and October 1976 have examined by whole body computerized axial tomography 121 patients, 76 males and 45 females, with an average age of 54.3 years.

Fortysix cases were normal, 16 presented clinical findings of acute pancreatitis, 26 of chlonic pancreatitis, 9 were affected by pancreatic tumors, 7 by various pathological processes and in 17 cases a definite diagnosis could not be reached.

Presented in detail are the techniques of examination and dis- cussed is the use of contrast media. In 44% of the cases the exami- nation was performed with the patient in the supine position, in 56% in the right lateral projection following the intake of gastro- grafin and in 80% by a combinat ion of both methods.

Reviewed and analyzed are the morphology and topographic ana tomy of the normal pancreas as demonstra ted by computerized axial tomography, the anomalies and external factors which may affect the contours and position of the pancreas, and the findings related to acute or chronic pancreatitis, to a pseudocyst and a pancreatic tumor.

An analysis of the results obtained in the 91 cases shows that a correct diagnosis of pancreatitis was reached in 29 cases, a false negative diagnosis was made in 9 and a non conclusive diagnosis in 20 cases.

Numerous and clear illustration accompany the article.

Antonio F. Govoni, M D