Effects of endoscopic variceal sclerotherapy on azygos vein blood flow and systemic haemodynamics

The present study was designed to determine the systemic haemodynamic effects of obliterating oesophageal varices by endoscopic sclerotherapy. We evaluated systemic and splanchnic haemodynamics before and after the first course of sclerotherapy in cirrhotic patients. The baseline cardiac index was significantly correlated with baseline azygos vein blood flow (r = 0.64; P < 0.01) and the azygos vein blood flow and cardiac index significantly decreased (-33% and -16%, respectively; P < 0.01) following sclerotherapy. The systemic vascular resistance index was also increased significantly (+ 20%; P < 0.01) in these patients. Moreover, the per cent change in azygos vein blood flow was directly correlated with that of the cardiac index (r = 0.51; P < 0.03). We conclude from these findings that the obliteration of portosystemic collaterals by sclerotherapy significantly reverses hyperdynamic circulation in such patients via a decrease in cardiac preload. The blood flow of the portosystemic shunt per se is a leading contributor to the hyperdynamic circulation observed in patients with well-developed portal systemic collateral vessels.     

Microvascular transplantation in the salvage of lower extremity trauma in the elderly

In the cadaver of an 86 year old man the inferior segment of the azygos vein could not be found. Furthermore, a normally developed hemiazygos vein drained the right and left intercostal veins from T 10 to T 6. This vessel finally curved towards the right to reach the superior vena cava after having drained the right superior intercostal veins. The left superior intercostal vein ended in a short vessel draining into the left brachiocephalic vein. This condition may be represented in a standard chest radiograph by the so-called "aortic nipple". Agenesis of the azygos vein, suspected because of the presence of this radiological sign, should be confirmed in the living by means of computerized tomography. This can clarify the anatomy of the mediastinal vessels precisely. Embryological pattern of the azygos system accounting for its possible defects is discussed.     

Rare malposition of a subclavian vein catheter

Deviation of a left subclavian vein catheter into the azygos vein occurred in a patient with cancer of the colon. On the p.a.-projection, the catheter seemed to be kinked in the vena cava. In the lateral view, the malposition in the azygos vein could be detected and was visualised by giving a bolus of contrast medium. By retracting the catheter under fluoroscopic control the proper position could be achieved. The importance of the lateral-view chest x-ray is discussed.     

Kinetic and spectroscopic characterization of an intermediate peroxynitrite complex in the nitrogen monoxide induced oxidation of oxyhemoglobin

A rare case of absence of the azygos vein associated with double superior vena cava is presented. Imaging findings on plain chest film and on contrast-enhanced computed tomography are described, and the embryology of azygos and hemiazygos veins is reviewed.     

Dilatation of the azygos vein: an unusual cause of pulmonary mass

Infrahepatic interruption of the inferior cava vein, is a rare congenital anomaly, usually associated with congenital heart and abdominal diseases. The systemic venous flow is accommodated by the dilated azygos. This dilated azygos arch accounts for the right paratracheal or mediastinal mass, and may be misinterpreted as a neoplasm. We report a case with this congenital vascular anomaly, associated with another of tracheobronchial tree.     

Anomalous azygos vein: a potential danger during endoscopic thoracic sympathectomy

A report of a patient with an azygos lobe and an associated anomalous azygos vein covering the upper thoracic sympathetic chain. This anomaly poses a significant risk during the procedure of endoscopic thoracic sympathectomy. A chest X-ray is useful in detecting this anomaly and alerting the surgeon to potential problems.     

Aneurysmal bulb dilation of the azygos vein: radiological and clinical significance

An aneurysm of the azygos vein is usually detected in the course of routine chest X-rays. It presents as a sharply circumscribed tumor shadow in the area of the right tracheobonchial angle or as an enlargement of the upper right mediastinum. A tentative diagnosis is supplemented both by further X-rays in a supine position in combination with the Valsalva and Müller tests and by tomography. The most frequent cause of an azygos aneurysm found in our material is aplasia of the inferior vena cava. Infrahepatic interruption of the inferior vena cava with azygos continuation can also be an associated malformation. Therefore, bilateral pelvic phlebography with visualization of the retroperitoneal venous and azygos systems is mandatory for establishing the correct, complete diagnosis. We have found no concomitant hemodynamic derangements. It is important to note that under these circumstances no therapy is indicated.     

Azygos reflux: a CT sign of cardiac tamponade

Three patients who were investigated with dynamic contrast medium enhanced computed tomography (CT) of the thorax were noted to have pericardial effusions with reflux of contrast medium back along the azygos vein. The diagnosis of cardiac tamponade was not made clinically, but in each case was suggested from the CT findings. Confirmation of the diagnosis was made in all three cases, two patients with echocardiography and one at post mortem. One patient made a rapid recovery following the insertion of a pericardial drain, another made a temporary recovery after pericardiocentesis but the third died. Thirty CT scans performed with similar protocol were reviewed and none of these demonstrated reflux along the azygos vein. The presence of contrast medium refluxing into the azygos vein implies significant haemodynamic disturbance, and in the presence of a pericardial effusion suggests the diagnosis of cardiac tamponade.     

What can we learn from the California mortality studies?

OBJECTIVES: The aim of this study was to compare the sensitivity of a newly applied transoesophageal ultrasonic Doppler sensor for detection of air with the traditional precordial ultrasonic Doppler sensor in clinical use. METHODS: We studied 16 patients undergoing neurosurgical procedures in a sitting position. Two ultrasonic Doppler devices were compared as to their ability to detect venous air embolisms (VAE): transoesophageal (ODM II, co. Abbott) versus a precordial ultrasonic Doppler sensor (Parks Medical Electronics Inc.). After establishing general anaesthesia and endotracheal intubation, we applied an ultrasonic Doppler sensor to the right sternal border of the patient's chest and inserted an ultrasonic Doppler probe into the oesophagus. With the patient in the sitting position, microparticularly d-galactose was injected to verify the efficacy of both ultrasonic Doppler devices. RESULTS: Using ODM II by positioning the probe toward the azygos vein, a dosage of 1 ml microparticularly d-galactose was detected in every patient. When adjusting the ODM II-probe on the right myocardial wall or using the precordial ultrasonic Doppler sensor, the administration of microparticularly d-galactose was detected by the devices in only 11 patients. CONCLUSIONS: This study demonstrates that a transoesophageal ultrasonic Doppler sensor (ODM II) is more efficient than the precordial ultrasonic Doppler sensor for monitoring patients who are at risk of VAE by sonification of the azygos vein.     

False positive MIBG scan

OBJECTIVE: An increased age-related incidence of oesophageal cancer in people with intellectual disability has been suggested by studies in the Netherlands. Gastro-oesophageal reflux disease (GORD), as documented by pH testing, occurs frequently in the intellectually disabled population, being found in nearly 50% of those with an IQ less than 50, while Barrett's oesophagus is found in about 15-26%. DESIGN: We compared the age-related incidence of oesophageal cancer in institutionalized, intellectually disabled individuals in the Netherlands with the age-related incidence in the general Dutch population. METHODS: Data were provided by the Netherlands Cancer Registry. The patient's institute physician was asked to complete a questionnaire about the diagnosis, which was endoscopically and histologically confirmed. RESULTS: The incidence of oesophageal carcinoma was 20 in 168,000 person-years. The expected incidence for oesophageal cancer, based on age-related incidence in the general population, was 7.0, resulting in a standardized morbidity ratio in the population with intellectual disability of 2.9 (confidence limits, 1.8-4.1; P < 0.001). Endoscopic findings were as follows: in 18/20 intellectually disabled carcinoma patients an adenocarcinoma was found; the remaining two patients had a squamous cell carcinoma. Barrett's epithelium was observed in nine patients (45%), eight (42%) of whom showed a peptic stricture as well. In 15 (75%) cancer patients reflux oesophagitis was found, accompanied in 14 cases by a hiatal hernia. CONCLUSION: A standardized morbidity ratio for oesophageal carcinoma of 2.9 was found in the intellectually disabled population as compared to the general population. Early detection and treatment of GORD in the population with intellectual disability is of paramount importance to prevent the development of Barrett's dysplasia and carcinoma.     

Species differences in carcinogenesis

The prognosis for carcinoma of the oesophagus is generally dismal especially when patients present late. Any clues to early diagnosis and management and identification of rapidly progressive variants are therefore helpful. Reports and review of the literature are presented with respect to four unusual cases of oesophageal carcinoma treated in the University of Ilorin Teaching Hospital in 1985 and 1986. Four men aged 59, 60, 55 and 60 years respectively presented with multiple polypoid carcinoma of the oesophagus, malignant oesophago-bronchial fistula at the level of the left main stem bronchus, achalasia co-existing with oesophago-gastric carcinoma and a small focus of carcinoma of the distal thoracic oesophagus presenting with widespread thoracic metastases and malignant pleural effusion mimicking advanced bronchogenic carcinoma. The unusual clinico-pathological features with the autopsy findings in the last case can influence diagnosis, management and prognosis of oesophageal cancer in general and of such cancer associated with pre-malignant conditions like achalasia and oesophageal polyps in particular.     

Levocardia with ventricular inversion and a single atrium in normal position

A 12-year child had complete heart block, an abdominal situs inversus with laevocardia. Further investigation demonstrated in addition an inferior vena cava ending into an azygos vein, a shunt at the atrial level and a pulmonary valve stenosis. At operation there was a lone atrium in normal position, a ventricular inversion without transposition of the great vessels. In spite of a corrective operation of the Mustard type, the child died the following day through haemorrhage and low output.     

Phase II study: concurrent chemo-radiotherapy in advanced nasopharyngeal carcinoma

Oesophageal carcinoma is a major cause of cancer death in certain parts of the world. Early detection provides the only chance of cure. In this study, one female and nine male patients with superficial oesophageal carcinoma were investigated to determine the pertinent clinical and pathological features. All male patients were smokers and six patients drank various amounts of alcohol on a daily basis. Histologically, five cases were confined within the mucosal layer and five within the submucosal layer. All five mucosal cancer cases and two of the five submucosal cancer cases were asymptomatic. Endoscopically, all five mucosal cancer patients had flat lesions, whereas the five submucosal cancer tumours appeared either protruding or depressed. Barium oesophagography failed to demonstrate the lesions in four of five mucosal cancer and one of five submucosal cancer cases. Endoscopic ultrasonography correctly detected the depth of cancer invasion in six out of eight superficial oesophageal carcinoma cases. All patients received a one-stage operation that included oesophagectomy and lymph node dissection. All five mucosal cancer patients had no lymph node involvement and have experienced no tumour recurrence. Among them, one who had concomitant hepatocellular carcinoma died early. Of the five submucosal cancer cases, four died 1-5 years after the operation. It is concluded that oesophageal carcinoma is curable in its early stage. Physicians should be alert while performing endoscopic examination. We believe that the dyeing technique is a useful adjunct to endoscopic examination.     

Clinical aspects and imaging patterns with ultrasonography and endoscopy in hepatosplenic schistosomiasis in Uganda

In patients with hepato-splenic schistosomiasis, a close relationship between the grade of periportal fibrosis and portal vein diameter, spleen size and presence of oesophageal varices and their grade was found.     

Infrahepatic interruption of the inferior vena cava with azygos continuation: a potential mimicker of aortic pathology

Infrahepatic interruption of the inferior vena cava (IVC) with azygos or hemiazygos continuation is a rare finding. In this anatomic entity, the intrahepatic segment of the IVC is absent, and the hepatic veins empty directly into the right atrium. Venous blood flow from the lower body is directed from the IVC into the azygos system at the level of the renal veins, with resultant dilation of the azygos and/or hemiazygos veins. Because these enlarged vessels lie parallel to the descending thoracic aorta, they may be mistaken for aortic pathology (dissection, aneurysm, or rupture) during transesophageal echocardiography (TEE). We describe a case of azygos continuation of the IVC initially misdiagnosed by TEE as partial aortic rupture. Repeat TEE with intravenous agitated saline injection correctly identified the condition, and the echocardiographic features are described.     

bcl-2 and p53 immunophenotypes in pre-invasive, early and advanced oesophageal squamous cancer

AIMS: An inverse correlation between bcl-2 and p53 expression has been reported in several types of epithelial tumour. The role of bcl-2 and p53 in the development of oesophageal squamous carcinoma has yet to be established. The expression of bcl-2 and p53 proteins has been evaluated in the multistage oesophageal tumorigenesis, which progresses from normal mucosa to dysplasia (squamous intraepithelial lesion, SIL), to invasive early and advanced oesophageal squamous cancer. METHODS AND RESULTS: Sixty-four cases of squamous oesophageal cancer, coexisting with SIL in 18 cases, were immunohistochemically analysed for any overexpression of bcl-2 and p53 proteins. Any association of bcl-2 and p53 protein expression with patient survival was also analysed. We observed bcl-2 expression that decreased significantly during the progression of oesophageal carcinogenesis. A decreasing frequency in the expression of bcl-2 in advanced oesophageal squamous cancer coincided with frequent p53 overexpression. bcl-2 expression was correlated with patient survival by univariate analysis. The association disappeared after adjusting for tumour stage, p53 overexpression showed no association with patient survival by either univariate or multivariate analysis. CONCLUSIONS: The down-regulation of bcl-2 and upregulation of p53 in advanced oesophageal squamous cancer suggest that bcl-2 and p53 proteins may interact in the progression of oesophageal squamous cancer.     

Histochemistry of mucin secreting components in mucoepidermoid and adenosquamous carcinoma of the oesophagus

AIMS: To determine the direction of differentiation of the mucin secreting components in a rare group of oesophageal tumours--oesophageal squamous cell carcinomas with prominent mucin secreting components (mucoepidermoid carcinomas and adenosquamous carcinomas). METHODS: In a review of 617 cases of primary carcinoma of the oesophagus, 16 cases of squamous cell carcinoma with prominent mucin secreting components were studied using a battery of histochemical techniques. RESULTS: The mucin produced by these tumours was mixed and included a variable content of enzyme labile sialomucin (positive for mucicarmine, periodic acid Schiff, and alcian blue, and sensitive to sialidase digestion and negative for high iron diamine-alcian blue). Retrospective analysis of endoscopic biopsy specimens taken from these tumours showed that mucin was present in five (42%) cases. CONCLUSIONS: The glandular component of this group of tumours histochemically differentiated in the direction of oesophageal glands: examination of the mucin secreting component in squamous cell carcinoma in resected specimens is therefore required for recording the true incidence of this type of tumour.     

Chemotherapy and radiotherapy as part of curative management of esophageal cancer

Chemotherapy and irradiation it combination or alone have been employed in the treatment of oesophageal carcinomas for many years. However, their place in curative treatment is not definitively clarified. Several non-randomized studies indicate an effect from combined chemotherapy and irradiation possibly followed by surgery. Randomized studies published during the last few years confirm an increased curability in patients who have received combined treatment. New multicentre trials show that a more aggressive attitude is indicated in selected groups of patients with oesophageal carcinoma. Due to the variable spectrum of the disease and complexity of the treatment the treatment should be given in centres which master the different modalities.     

Down-hill varicose veins in struma permagna and unilateral hypoplasia of the internal jugular vein]

A barium oesophagogram of a 69-year old woman suffering from dyspnoea, episodes of suffocation and dysphagea because of massive struma, showed multiple uniform nodular filling defects in the upper oesophageal relief corresponding to downhill varices. In CT scan and MRT additionally a pathogenetic relevant hypoplasia of the right internal jugular vein was evident.     

Cost-effectiveness in the management of patients with oesophageal cancer

BACKGROUND: The aim of this study was to assess the relationship between clinical outcome, quality of life and cost for treatment modalities commonly employed in the management of oesophageal carcinoma. METHODS: A series of 51 patients diagnosed with oesophageal carcinoma in a 6-month period was used to derive a cost analysis profile for their treatment. All patients underwent quality of life assessment. Patients diagnosed in 1993 and managed in Newcastle upon Tyne were identified from the Northern Cancer Registry and Hospital Episode Statistics. Intervention profiles were documented for a 3-year follow-up period and cost analysis was conducted. A further 51 patients were recruited prospectively for quality-of-life studies. RESULTS: Some 139 individuals were identified retrospectively. Median survival was significantly better in patients treated by resection (n=31; median 20 months) than in those receiving palliative treatments (n=108; median 6 months) (P < 00001). Median cost was significantly greater in individuals who underwent resection (8070 pound sterling) than for patients subjected to a palliative strategy (radiotherapy 4720 pound sterling, brachytherapy 1790 pound sterling, laser 3540 pound sterling, intubation 2450 pound sterling, no treatment 1390 pound sterling) (P < 0.01). When considering the median cost per month of life (after treatment) resection (457 pound sterling) compared favourably with the palliative options (range 342-1125 pound sterling). CONCLUSION: Surgical resection for oesophageal carcinoma confers greatest benefit in terms of survival. Costs are inherently greater in individuals undergoing resection but, allowing for time, resection is at least as cost-effective as other treatment modalities.