Comparative morphologic study of the pathogenic properties of different agents of intestinal infections

Percutaneous transjugular cholangiography (PTJC) is a new technique for visualization of the biliary duct system and for diagnosis of obstructive jaundice. First experiences of the authors in 22 patients are described. The advantages and disadvantages of this procedure, which at the present time is used rather rarely, are discussed and compared to various other cholangiographic methods. The endoscopic retrograde cholangiography (ERC) was used for patients with obstructive jaundice of unknown origine in the first place. If the biliary duct system could not be visualized by ERC (failure of complete obstruction of the common bile duct), the antegrade technique (PTJC) was performed. The peritoneoscopic and the transjugular cholangiography yield about the same percentage of positive results (90%), as far as visualization of the biliary tree is concerned. However in contrast to the peritoneoscopic methods PTJC seems to bear a smaller risk of complications. Some further diagnostic and therapeutical advantages, which might result from the use of PTJC are pointed out.     

Primary small bowel lymphoma manifested as obstructive jaundice in a patient with AIDS

We describe a patient with acquired immunodeficiency syndrome (AIDS) and non-Hodgkin's lymphoma of the duodenum manifested as obstructive jaundice. Endoscopic retrograde cholangiography led to the diagnosis and was used to relieve the obstruction. The patient received chemotherapy and is in remission 21 months after the diagnosis, thus justifying an aggressive approach toward diagnosis and treatment in this patient population.     

Value of MR cholangiography in the diagnosis of obstructive diseases of the biliary tree: a study of 58 cases

OBJECTIVE: The aim of this study was to evaluate magnetic resonance cholangiography (MRC) in the diagnosis of biliary tree obstruction. METHODS: Fifty-eight consecutive patients underwent MRC (GYROSCAN ACS II 1.5 Tesla, TSE T2 axial/coronal-MIP sequences) for clinical and biochemical signs of main bile duct obstruction. MRC images were interpreted by two radiologists and consensus was established according to presence or absence of main bile duct dilation, choledocholithiasis, and malignant or benign stricture. MRC was compared to a final diagnosis established by ultrasound and CT in 19 cases, endoscopic retrograde cholangiopancreatography (ERCP) in 25, intraoperative cholangiography and exploration in 14, and clinical, biochemical, and histological presentation when relevant. Included were single or multiple choledocholithiasis (28, including 11 < or = 3 mm), malignant (10) and benign (12) strictures, and intrahepatic cholestasis (9). RESULTS: Overall, MRC was sensitive (94%) and specific (92%) in detecting main bile duct dilation and choledocholithiasis (86 % and 97 %), but was less sensitive (64%) for small stones < or = 3 mm. Sensitivity for stones > 3 mm was 100%. For benign and malignant strictures, MRC was less sensitive (67% and 80%) but remained specific (98% and 96%). In the detection of normal main bile duct, MRC was highly sensitive (100%) and specific (94%). Diagnostic accuracy ranged from 91% to 98%. CONCLUSION: MRC appears to be specific for choledocholithiasis and sensitive except for small stones. Results for biliary stricture are less satisfactory, but remain specific. Our data confirm that MRC can be useful in the diagnostic workup of main bile duct obstruction.     

Value of endobiliary brush cytology and biopsies for the diagnosis of malignant bile duct stenosis: results of a prospective study

BACKGROUND: Before considering a nonsurgical method of management of a bile duct stenosis, a tissue diagnosis is highly desirable. In a prospective study we have evaluated the feasibility and reliability of endobiliary brush cytology and biopsies performed at the time of endoscopic retrograde cholangiography. METHODS: Two hundred thirty-three consecutive patients underwent an attempt at endobiliary brush cytology and biopsies of bile duct stenosis when no mass was detected on ultrasound and CT scan. RESULTS: The material for cytology was sufficient for analysis in 210 cases (90%) and biopsies were obtained in 128 cases (55%). One hundred fifteen patients had both cytology and biopsies (49%). For the diagnosis of malignant stenosis, the sensitivity was 35% for cytology, 43% for biopsies, and 63% for the combination of cytology and biopsies. For both cytology and biopsies, the specificity was 97%. In the cases of cancer primarily involving the bile ducts, the sensitivity was 86% when combining both cytology and biopsies. CONCLUSIONS: Endobiliary sampling is technically difficult and has a limited sensitivity for the diagnosis of malignant biliary stenosis. Biopsies should be combined with cytology to increase the sensitivity.     

Rat bone marrow-derived mast cells co-cultured with 3T3 fibroblasts in the absence of T-cell derived cytokines require stem cell factor for their survival and maintain their mucosal mast cell-like phenotype

The aim of this study was to compare the accuracy of computed tomography (CT) and single photon emission computerized tomography (SPECT) in the diagnosis of dementia. Fifty-two patients with clinical diagnosis of dementia and 11 controls were studied. The scans were interpreted by one experienced neuroradiologist and one nuclear radiologist, both blinded to the clinical data. In the diagnosis of dementia, CT and SPECT showed equal sensitivity (82.7%) and statistically similar specificity (63.8 and 81.8%, respectively). The specificity of SPECT in diagnosing Alzheimer's disease (100%) was statistically superior to CT (69%). However, both methods showed similar sensitivity in detecting Alzheimer's disease. In conclusion, SPECT and CT showed similar accuracy in the diagnosis of dementia. The quite high specificity of SPECT in Alzheimer's disease may be useful for confirming that diagnosis, particularly for patients with presenile onset of the disease.     

Thin needle cholangiography: experience with 50 patients

Thin needle cholangiography (TNC) was performed in 50 patients with obstructive jaundice or jaundice of obscure origin. The purpose of this study was to assess the diagnostic accuracy and safety of this procedure. TNC was performed by the technique described by Redeker et al. using the Chiba needle (JAMA 231:386, 1975). Obstructed ducts were successfully demonstrated in 100% of cases (29/29). Non-obstructed ducts were opacified in 12/21 (57%). Overall success was 82% (41/50). Two septic complications occurred. It is concluded that 1) TNC is a highly reliable, easy to perform and safe procedure in the evaluation of the jaundiced patient; 2) Accurate demonstration of the biliary anatomy by TNC provided important information which often in (10/50 = 20%) led to a change in diagnosis, avoidance of unnecessary procedures, and shortening of hospitalization; 3) Failure to visualize patients with non-dilated biliary ducts occurred with advanced chronic liver disease or fatty liver.     

Using unenhanced helical CT with enteric contrast material for suspected appendicitis in patients treated at a community hospital

OBJECTIVE: We evaluated the accuracy of unenhanced helical CT with enteric contrast material in the diagnosis of appendicitis in children and adults treated at a community hospital. SUBJECTS AND METHODS: Over an 8-month period, 100 consecutive patients with right lower quadrant pain and suspected appendicitis were prospectively evaluated. Thin-collimation helical CT scanning was performed after administration of enteric contrast material. CT interpretations were correlated with surgical pathology (45 patients) and clinical follow-up (55 patients). RESULTS: The findings of 33 CT scans were interpreted as positive for appendicitis (29 true-positives and four false-positives), and the findings of 67 were interpreted as negative for appendicitis (66 true-negatives and one false-negative). Sensitivity was 97%, specificity was 94%, accuracy was 95%, positive predictive value was 88%, and negative predictive value was 99%. In the 67 CT scans with negative findings for appendicitis, an alternative diagnosis was made for 36 patients (54%). CONCLUSION: Unenhanced helical CT with enteric contrast material for the evaluation of appendicitis can be implemented in a community hospital. In our study, such imaging achieved excellent accuracy.     

Combined use of duplex imaging and magnetic resonance angiography for evaluation of patients with symptomatic ipsilateral high-grade carotid stenosis

PURPOSE: Advances in cerebral vascular imaging suggest that patients with critical levels of carotid artery stenosis (> 70%) who have symptoms can be identified accurately and necessary information about the intracranial and extracranial circulation obtained before surgery without conventional angiography. We have used carotid duplex imaging in combination with magnetic resonance angiography (MRA) to evaluate 20 patients with symptomatic ipsilateral high-grade carotid stenosis. METHODS: All patients underwent CT and magnetic resonance imaging brain scans, as well as MRA and conventional arteriography of the cerebral circulation. Magnetic resonance angiograms were obtained with two-dimensional phase contrast and time-of-flight techniques. Phase contrast was used for intracranial vascular imaging and for determining qualitative flow velocities and the direction of blood flow in the circle of Willis. Two-dimensional time of flight was used to assess the carotid bifurcations. RESULTS: Twenty patients with symptoms (six with strokes, 11 with transient ischemic attacks, and three with amaurosis fugax) had duplex evidence of high-grade carotid stenoses. Computed tomographic and magnetic resonance brain scans were positive for cerebral infarction in six patients with clinical strokes. Comparison of MRA with conventional angiography was 91% accurate for high-grade stenoses and occlusions (sensitivity 100% and specificity 90% for stenosis; sensitivity/specificity was 100% for complete occlusion). Comparison of duplex imaging with conventional angiography demonstrated 86% accuracy for detection of severe stenosis or occlusion (sensitivity 94% and specificity 89% for stenosis; sensitivity and specificity were 100% for complete occlusion). CONCLUSIONS: This study suggests that combined use of MRA and duplex imaging is accurate for detection and evaluation of high-grade carotid stenoses in patients with symptoms.     

The current aspects of seroepidemiological research in combined foci of leishmaniasis

The accuracies of ultrasonography (US) and computed tomography (CT) for determining tumor invasion of the chest wall in lung cancer were compared in a retrospective study of 120 patients. US findings were evaluated preoperatively according to the following criteria: disruption of pleura, extension through the chest wall, and fixation of tumor during breathing. CT findings were evaluated with the following criteria: obtuse angle of the mass to the pleural surface, more than 3 cm contact with the pleural surface, and visible pleural thickening associated with the mass. Chest wall invasion was judged as positive when at least two of the three findings were present with either technique. Nineteen of the 120 patients had chest wall invasion by tumor. The sensitivity of US was 100% and the specificity was 98%. The sensitivity of CT was 68% and the specificity was 66%. The accuracy of US and CT were 98% and 67%, respectively.     

Variations of the flexor digitorum superficialis tendon of the little finger

The use of 131I doses of several mCi for scans can stun the thyrocytes and thyroid cancer cells, whereas the usual dose (300 microCi) of 123I does not. We compared the diagnostic accuracy of the 123I (300 microCi) scans and that of 131I (3-10 mCi) scans in 155 patients. The diagnostic accuracy of a 123I scan in detecting functioning thyroid remnant/metastasis was 89.5% (77/86 scans) and that of a 131I scan was 92.9% (39/42) in 6 week-postoperative patients (p = 0.750). For radioablation therapy follow-up patients, the diagnostic accuracy of 123I in determining presence or absence of functioning remnant or metastasis was 69.4% (25/36) and that of 131I was 92.5% (49/53) with a p value of 0.079. The success rates for complete ablation of functioning tissue after radioiodine therapy administered after diagnostic 123I and after 131I were 72% (34/47) and 56% (24/43), respectively, with a p value of 0.125. Our study indicates the following: 1) for the first postoperative evaluation, the diagnostic accuracy of the 123I scan was essentially equal to that of the 131I scan, and the success rate of radioablation therapy appears to be better than 123I scan; and 2) for postablation follow-up surveys, the 131I scan appears to be better but carries the risk of stunning the functioning cells.     

Role of endorectal ultrasonography and CT in preoperative staging of rectal cancer. Personal experience]

We report our personal experience on endorectal US and CT in the preoperative staging of rectal carcinoma. Our series includes 64 cases (38 male and 26 female) evaluated with intrarectal sonography; 38 of these patients underwent also CT-study of the lower abdomen. Using both imaging techniques infiltration of the rectal wall and adjacent structures and lymph node involvement were studied. The results of our study refer to 58 patients who underwent endorectal US, 31 of whom studied also with CT. Referring to the T-parameter with ultrasound 41 correct diagnosis were obtained, in 13 cases the lesion was over-staged and in 4 cases understaged. The sensitivity, specificity and diagnostic accuracy was respectively 89.5%, 60% and 79.3%. With CT 23 diagnosis were correct, in 1 case the lesion was overstaged and in 7 cases understaged; sensitivity, specificity and diagnostic accuracy concerning rectal wall infiltration were respectively 72%, 83.3% and 74.2%. The evaluation of the N-parameter demonstrated low value of sensitivity with both US (15.8%) and CT (42.9%). Considering the results of our series, we feel that it is necessary to use both imaging techniques because results obtained are complementary referring to the T-parameter, although N-parameter were a little significant.     

CT angiography versus intraarterial digital subtraction angiography for assessment of aortoiliac occlusive disease

OBJECTIVE: The purpose of this study was to evaluate the accuracy of CT angiography (CTA) with a single helical acquisition for assessment of stenoses and occlusions of the iliac arteries. SUBJECTS AND METHODS: In our prospective study, intraarterial digital subtraction angiography and IV CTA were performed from the suprarenal aorta to below the femoral bifurcation in 30 patients with vascular occlusive disease. Maximum-intensity-projection images in multiple views were also obtained. The accuracy of CTA with and without analysis of axial images was determined. RESULTS: Sensitivity and specificity of CTA were 100% for iliac artery occlusions with a confidence interval 85-100% and 97-100%, respectively. When axial scans were interpreted, 14 of 15 high-grade (> 75%) stenoses were recognized. Sensitivity and specificity of CTA were 93% (range, 68-100%) and 99% (range, 97-100%), respectively. When maximum intensity projections alone were analyzed, sensitivity for the diagnosis of 15 high-grade stenoses was only 53% (range, 27-79%) because calcified plaques obscured six stenoses. CONCLUSIONS: CTA accurately reveals iliac artery occlusions. Observers of CT angiograms may overlook short stenoses in rare instances. Calcified plaques limit the use of maximum-intensity-projection images.     

Appendiceal CT in 140 cases. Diagnostic criteria for acute and necrotizing appendicitis

Computed tomography (CT) was performed in 140 patients with suspected acute appendicitis. Thin collimation (5 mm), intravenous contrast enhancement, 1-second scan times, and supplementary cecal air insufflation were emphasized. CT accuracy was 98% overall (137/140), and 99% in the 124 cases with early surgery. Necrotizing appendicitis was diagnosed by CT with 86% accuracy and 90% positive predictive value.     

Functional defects of Cx26 resulting from a heterozygous missense mutation in a family with dominant deaf-mutism and palmoplantar keratoderma

BACKGROUND: There is controversy about the impact on morbidity from delayed diagnoses of blunt hollow viscus injuries. A recent study suggested that the increased morbidity was primarily from delayed diagnosis of blunt duodenal injury (BDI). STUDY DESIGN: We studied the medical records from a 10-year period from June 1987 to June 1997 examining the data on 22,163 cases of blunt trauma. We assessed the incidence and consequences of delayed diagnoses of BDI, and identified preoperative factors associated with these delayed diagnoses. RESULTS: Thirty-five patients (0.2%) were identified in the retrospective study of the records from 22,163 blunt trauma patients to have sustained BDI. Of these, 25 patients (71%) were male. Ages ranged from 1 to 58 years (mean 18.8 years), and the predominant mechanism was motor vehicle accident in 18 patients (51%). Seven patients (20%) (group I) had a diagnostic delay of > 6 hours; 28 patients (80%) (group II) were diagnosed in < 6 hours. Six of the seven group I patients (86%) were evaluated initially with CT scans, and five (83%) showed findings suggestive of BDI. Among the 28 group II patients, 14 (50%) underwent initial diagnostic peritoneal lavage (DPL), and 14 (50%) had a CT scan. In seven of the group II patients (50%) who were initially evaluated by CT scan, there were findings suggestive of BDI. Diagnostic peritoneal lavage was initially equivocal (red blood cell count=5,000 to 100,000) in the remaining one group I patient compared with three of the group II patients who had DPL. Deterioration found on physical examinations prompted followup CT scans in 6 group I patients (86%), and the scans were diagnostic for BDI in all cases. CONCLUSIONS: Blunt duodenal injury is an uncommon entity. Despite the presence of suggestive CT and DPL findings, the diagnosis was delayed in 20% of the 35 patients whose records were examined in the study; this delayed diagnosis was associated with increased abdominal complications. Patients with persistent abdominal complaints and equivocal CT or DPL findings should undergo laparotomy or repeat CT scan evaluations.     

Adrenal nonhyperfunctioning adenoma and nonadenoma: CT attenuation value as discriminative index

BACKGROUND: When an asymptomatic adrenal mass is incidentally discovered on abdominal CT scans, the distinction between a nonhyperfunctioning adenoma and a nonadenoma would be important. METHODS: We evaluated the CT findings of 36 adrenal masses (14 nonhyperfunctioning adenomas, 22 nonadenomas) in 34 patients with no evidence of hormonal hypersecretion. CT attenuation values of adrenal masses on CT scans were calculated by setting a circular region of interest as large as possible in the center of each adrenal mass. RESULTS: Below 20 HU in CT attenuation values, all adrenal masses, except one case of ganglioneuroma with myxomatous change, were nonhyperfunctioning adenomas. With an arbitrary threshold of 20 HU, the sensitivity of CT attenuation values in distinguishing nonhyperfunctioning adenomas from nonadenomas was 64%, the specificity was 95%, and the accuracy was 83%. When decreasing the threshold to 15 HU, the sensitivity was 64%, the specificity was 100%, and the accuracy was 86%. The CT attenuation value on noncontrast CT was more useful for making this distinction than the size and interior homogeneity. CONCLUSIONS: Our data suggest that an asymptomatic adrenal mass with homogeneous low attenuation (< or = 15 HU) and less than or equal to 4 cm indicates a nonhyperfunctioning adenoma, and no further examinations are necessary. CT attenuation value on non-contrast CT is the most important discriminatory factor.     

Pancreatic tumors: comparison of dual-phase helical CT and endoscopic sonography

OBJECTIVE: The purpose of this study was to compare dual-phase helical CT and endosonography for the diagnosis and staging of pancreatic tumors. SUBJECTS AND METHODS: Thirty patients with suspected pancreatic tumors underwent endosonography and dual-phase helical CT. A pathologic diagnosis was obtained in all cases with surgery (n = 23) or biopsy (n = 7), resulting in 27 neoplasms. Dual-phase helical CT and endosonographic findings were correlated with surgical and pathologic findings to determine diagnosis and resectability of pancreatic tumors. RESULTS: Overall diagnostic sensitivity was 92% for dual-phase helical CT and 100% for endosonography (p = .45). Overall accuracy for staging of pancreatic tumors was 93% for both dual-phase helical CT and endosonography. Overall accuracy for predicting resectability was 90% for both dual-phase helical CT and endosonography. Accuracy of predicting unresectability was 100% for dual-phase helical CT and 86% for endosonography (p > .80). Differences were not considered statistically significant. CONCLUSION: Dual-phase helical CT and endoscopic sonography do not differ significantly for diagnosis and assessment of resectability of pancreatic tumors.     

Technetium-99-labeled leukocytes in diagnosing diabetic osteomyelitis in the foot

Hexamethylpropylamineoxine (HMPAO)-labeled leukocytes were studied to examine the scintigraphic significance of the procedure in diagnosing bone infection in patients with chronic nonhealing foot ulcerations. Fifty-two patients were scanned with Technetium-99-labeled white blood cells and scintigraphic results were compared with histological analysis, bone culture, and radiographic findings. Twenty-one patients demonstrated positive uptake with imaging and focal accumulation of leukocytes at the area of suspected infection. Sensitivity, specificity, and accuracy were calculated and found to be 86%, 90%, and 88%, respectively. Thirty-one members of the population were also scanned with Tc-99 methylene diphosphate (MDP) triphasic scintigraphy. Sensitivity equaled 91% and specificity was found to be significantly lower (40%) when compared with the leukocyte-labeled scans. Technetium-99 (HMPAO) leukocyte scintigraphs demonstrated a significantly higher specificity and accuracy rate when compared with Technetium-99 (MDP) triphasic scans.     

Segment III cholangiojejunostomy for carcinoma of the gallbladder

Jaundice in patients of advanced carcinoma of the gallbladder requires palliation for the distressing symptoms of pruritus and cholangitis. Intrahepatic segment III duct cholangiojejunostomy is a means for alleviating the obstruction with malignant porta block. The authors reviewed their experience with this procedure in 48 patients of carcinoma of the gallbladder. All patients had jaundice; pruritus was present in 44 (92%) and cholangitis in 14 (29%). The level of obstruction was determined preoperatively by percutaneous transhepatic cholangiography. In 32 patients the block was below the level of the bifurcation of the right and left ducts, and 16 patients had a block involving the confluence, isolating the two lobes of the liver. Following segment III cholangiojejunostomy, pruritus was relieved in all and cholangitis in 86% of patients. At the end of 6 weeks a significant fall in serum bilirubin and alkaline phosphatase levels was seen with both types of hilar obstruction. Varying degrees of pain relief was also noted in 75% of patients. Segment III biliary bypass is an effective, one-time, reliable means of palliation for carcinoma of the gallbladder with hilar obstruction. Its efficacy appears to depend on the duration and depth of the jaundice and on the anatomy of the biliary ductal system in the left hemiliver rather than on the type of hilar obstruction.     

A comparison of noninvasive imaging modalities in the melanoma patient

The results of radionuclide (RN) liver scans, computed tomography (CT), and ultrasonography (US) were compared in 163 patients. Thirty-eight patients had all three studies, while ten were examined by CT and RN liver scans. One hundred fifteen patients had only US and RN studies. Radionuclide liver scanning demonstrated more false positive and negative studies than CT or US. Also, CT and US demonstrated more areas of metastasis during a single examination than RN liver scans. Ultrasonography displayed roughly the same accuracy of CT when a technically adequate examination was obtained. However, US was hampered by technically inadequate studies in 19% of 153 patients because of interfering intestinal gas. Computed tomography proved the most accurate and reliable modality in 48 patients.     

Role of 99mTc-labeled RBC SPECT in the diagnosis of hepatic hemangioma--comparison with US, CT and angiography

The roles of planar imaging and SPECT with 99mTc-labeled RBC, US, Dynamic CT and angiography in the diagnosis of hepatic hemangioma were evaluated. The study group consisted of 18 patients with a total of 40 hemangiomas and 13 patients with a total of 21 non-hemangiomas. Among these patients, 5 patients with a total of 8 hemangiomas and 10 patients with a total of 14 non-hemangiomas were diagnosed by operation and biopsy. In all 40 hemangiomas, sensitivity for planar imaging was 35%, SPECT 50%, US 53%, Dynamic CT 82% and angiography 81%, respectively. When the tumor size was greater than 2.2 cm by SPECT and 2.8 cm by planar imaging, their sensitivity for both methods was 100%. Specificity for planar imaging was 100%, SPECT 95%, US 81%, Dynamic CT 100% and angiography 83%, respectively. One patient with hepatocellular carcinoma diagnosed by angiography showed increased uptake on SPECT. Because of the highest accuracy for SPECT in hemangioma greater than 2.0 cm, SPECT should be considered to be the method of choice for noninvasive diagnosis of hemangioma.