Angiography in chronic/recurrent gastrointestinal bleeding: a nine year study.

Undiagnosed chronic/recurrent gastrointestinal bleeding, as defined, is a severe problem to those afflicted, both physically and psychologically as well as socioeconomically. During the past nine years, 60 such patients received aortography and panvisceral arteriography (that is, celiac, superior mesenteric, and inferior mesenteric arteriography) in a search for the lesions that may be responsible for the bleeding. Results of angiography were "positive" in 26 patients for a diagnostic yield of 43 per cent. Fifteen of the 26 patients with positive angiographic findings demonstrated arteriovenous malformations of the gastrointestinal tract. Two separate lesions were identified in three patients. This series is compared with other published series of angiography for chronic gastrointestinal bleeding. One difference from the other series is the demonstration of three patients with arteriovenous malformation of the gastric antrum. The diagnostic angiographic features of this condition are presented, along with the interestng finding of état mammelonné in two of the three patients. Another difference from the other series is the demonstration of four arteriovenous malformations involving the left side of the colon, whereas other series report none in this location. One possible explanation for this descrepancy is our routine use of inferior mesenteric arteriography in all cases of chronic gastrointestinal bleeding. Ten arteriovenous malformations of the colon are reported along with a review of the angiographic diagnostic features in this condition. The precise incidence of false-positive and false-negative diagnoses is unknown since surgery was not performed on all patients. However, each patient studied represented a total failure, by traditional diagnostic studies, to determine the cause of bleeding. The incidence of positive findings with angiography (43 per cent) in patients with undiagnosed chronic/recurrent gastrointestinal bleeding is sufficient to encourage the continued use of panvisceral arteriography in this condition.     

The role of angiography in cryptogenic submesocolic digestive tract bleeding]

Three cases of chronic gastrointestinal bleeding are described; the Authors emphasize the important role of mesenteric arteriography in establishing site and nature of bleeding. The review of international literature shows a success rate between 41 and 73% of cases studied with this method after negativity of other diagnostic procedures.     

Primary lymphoma of the large intestine

Three cases of primary colonic lymphoma are presented and the literature for this disease is reviewed. Colonic lymphoma occurs in from 0.5 to 2 per cent of all cases of neoplastic disease of the colon, and comprises 15 to 20 per cent of cases of primary gastrointestinal lymphoma. The disease can occur at any age, from 3 years to 89 years; the average age is 50 years. Men are affected twice as often as women. The disease most commonly presents as a painful abdominal mass. The cecum is the area of involvement in 70 per cent of cases. The tumors are usually large, averaging over 7 centimeters. The most common histological types are histiocytic or lymphocytic tumors. Surgery is the principle treatment mode; about half are thought to be potentially curable at the time of surgical exploration. The role of adjuvant therapy has not yet been clearly defined, although data from some studies indicate increased survival in those patients given adjuvant radiation therapy. Survival is decreased in patients with tumors larger than 5 centimeters or with histiocytic cell type. Overall 5-year survival is 39 per cent.     

内脏动脉瘤的诊断与治疗

目的　探讨内脏动脉瘤的诊断和治疗方法。方法　回顾性总结我院40 多年来收治的62 例内脏动脉瘤的临床经验。结果　本组包括肝动脉瘤15 例,胃胰十二指肠动脉瘤13 例,脾动脉瘤16 例,肾动脉瘤6 例,肠系膜上、下动脉瘤分别为5 例和1 例,腹腔干动脉瘤3 例,网膜动脉瘤3 例。本组自发性破裂大出血29 例,其中破裂入胆管14 例,上消化道10 例,腹腔及腹膜后5 例。本组术前经内脏动脉造影确诊37 例,经磁共振( MRI) 及数字减影血管造影术( DSA) 确诊各2 例,另6 例由螺旋CT 动脉造影(SCTA) 诊断。手术治疗51 例,死亡9 例,动脉栓塞治疗6 例。结论　内脏动脉瘤术前临床诊断极为困难,选择性内脏动脉造影( 包括DSA) 最具诊断价值,一旦确诊应尽早手术治疗     

Lower gastrointestinal bleeding: an unusual presentation for blunt abdominal trauma.

A case of mesenteric vascular injury secondary to nonpenetrating steering wheel abdominal trauma is presented. Unique to this report is the presentation of blunt abdominal trauma as acute lower gastrointestinal bleeding with demonstration of the lesion preoperatively via selective celiac and superior mesenteric arteriography.     

Treatment of mesenteric infarction

Eighty-one cases of mesenteric infarction documented by angiography, laparotomy or autopsy were reviewed to assess the cause of the persistently high mortality. Thirty-seven patients (46 per cent) were felt to have inoperable lesions and were treated by supportive care only, while forty-four (54 per cent) underwent bowel resection and/or revascularization. Of these 44 patients 20 (45 per cent) survived, 14 (32 per cent) died of an early recurrence of infarction and 10 (23 per cent) died of an unrelated cause. In view of the high recurrence rate in the early postoperative period, treatment must prevent the causes of persistent or recurrent ischaemia such as vasoconstriction and reperfusion tissue damage. On the basis of recent clinical and experimental research we suggest that treatment should include routine angiography with selective perfusion of vasodilators through the superior mesenteric artery, pharmacological prevention of ischaemic and reperfusion tissue damage before surgery, and postoperative anticoagulation.     

Superior mesenteric artery syndrome: an uncommon cause of upper intestinal obstruction

A previously healthy young boy who was operated for upper gastrointestinal obstruction, 12 weeks earlier, without relief of his symptoms of projectile bilious emesis and colicky pain, is described. He underwent upper gastrointestinal contrast studies, suggesting duodenal obstruction at its third part and superior mesenteric artery syndrome, which was confirmed by selective superior mesenteric arteriography. Duodenojejunostomy was carried out. The patient was symptom-free with normal built and growth after 4 years of follow-up.     

Surviving gastrointestinal infarction due to polyarteritis nodosa: a rare event.

Poly arteritis nodosa (PAN) is a systemic vasculitis with a male: female ratio of 2:1 and a peak incidence in the fifth decade. Small to medium-sized arteries are involved by focal transmural inflammatory necrosis. Aneurysms with inflammatory destruction of the media also occur. The most frequently involved organs are the kidney, heart, lung, liver, and gastrointestinal tract. There are few reported cases of ischemic necrosis of the intestine and even fewer survivors. A 22-year-old woman was transferred to St. Thomas Hospital (Nashville, TN) after resection of 80 per cent of the small bowel for ischemic necrosis. She had a history of juvenile onset diabetes mellitus, recurrent abdominal pain, and splinter hemorrhages. Emergency aortogram and selective mesenteric arteriogram were performed. The celiac artery was not visualized and small aneurysms were present in the mesenteric and renal arteries. The patient was successfully resuscitated from a cardiac arrest in x ray from a cardiac tamponade. Laparotomy was performed to determine the viability of the bowel. The celiac, hepatic, and splenic arteries were found to be chronically occluded. Pathology of these arteries revealed a nonspecific arteritis. At a third operation, several more inches of small bowel were removed. Characteristic changes of PAN were present on all small bowel specimens. She was treated with high-dose cyclophosphamide and steroids for 6 months and has continued on low-dose cyclophosphamide. She is now 36 months from her original operation and is doing well on oral nutrition. Intestinal hemorrhage from aneurysm rupture or gangrene with perforation are gastrointestinal complications of PAN that the surgeon may be called upon to treat.(ABSTRACT TRUNCATED AT 250 WORDS)     

Arteriovenous malformation of the jejunum in a child

Arteriovenous malformation of the intestine is an uncommon cause of gastrointestinal hemorrhage, and the diagnosis can be made only by selective mesenteric arteriography to demonstrate the characteristic appearance. This is a case report of a 16-year-old boy with arteriovenous malformation of the jejunum causing massive rectal bleeding. We advocate the use of selective visceral angiography for diagnosing arteriovenous malformations of the intestine, even in children.     

Diverticular disease of the colon. A frequent cause of massive rectal bleeding

Hemorrhage from diverticular disease of the colon is the third most common cause of significant rectal bleeding. The patients are elderly and frequently have major coexisting disease. Hemorrhage will stop with nonsurgical treatment in the majority of cases. However, 17.3 per cent of patients in this study required surgical intervention to control the hemorrhage. The mortality was 11.7 per cent, and 58.8 per cent of the surgically treated patients had complicated postoperative courses.In the past a precise diagnosis has not been possible to make. The rate of diagnostic error in the surgical cases was 26 per cent. It is hoped that the increased use of selective mesenteric artery catheterization in the diagnosis and treatment of patients will afford them better management in the future.     

Small bowel melaena: 2 cases diagnosed by angiography

Two cases of small bowel tumour presenting with melaena are reported. Selective visceral arteriography was found to be invaluable in the management of these cases. The first case presented with intermittent bleeding causing anaemia. Conventional barium studies of the small and large bowel revealed no abnormality. Superior mesenteric angiography revealed a mass lesion in the jejunum, with features characteristic of a leiomyoma. The second case presented with massive gastrointestinal bleeding. Selective visceral angiography was performed initially and revealed a large, mainly avascular, mass lesion in the ileum. Pathological examination showed a leiomyoma which had undergone cystic degeneration. The value of selective angiography in patients with suspected small bowel bleeding is discussed..     

Unusual problems in parathyroid surgery

Although parathyroid surgery is difficult because of the smallness of the glands and the variability in their location and number, a surgeon who is well versed in the embryology, gross anatomy, pathology of the glands, and the fine points of gross identification of normal and abnormal tissue should be able to identify these glands in most instances. In a review of 122 cases during a two year period, pathologic change was found in 96 per cent, even though 11 per cent were secondary cervical explorations and the mediastinum was entered by a sternal split approach in only two cases. Although the abnormal glands were found in varying locations and ten were outside the usual areas of search, all were consistent with failure to descend or excessive descent and with a relationship to anatomic structures having similar embryologic origin. Sophisticated localizing procedures such as arteriography and selective venous sampling for parathormone are rarely necessary.     

内脏动脉瘤诊治经验

目的　探讨内脏动脉瘤的诊断和治疗方法。方法　对 71例内脏动脉瘤的诊断和治疗进行回顾性总结。结果　 71例内脏动脉瘤中包括脾动脉瘤 2 2例 ,肝动脉瘤 16例 ,腹腔干动脉瘤 4例 ,胃、胰十二指肠动脉瘤 13例 ,肠系膜上、下动脉瘤分别为 6例和 1例 ,网膜动脉瘤 3例 ,肾动脉瘤 6例。本组自发性破裂大出血 2 9例 ,其中破裂入胆道 14例 ,上消化道 10例 ,腹腔及腹膜后 5例。术前经内脏动脉造影确诊 (包括DSA) 4 2例 ,螺旋CT血管造影 (SCTA)证实 14例 ,经核磁共振血管造影 (MRA)确诊 4例。手术治疗 5 8例 ,死亡 9例 ;动脉栓塞治疗 7例。结论　内脏动脉瘤术前临床诊断极为困难。DSA、SCTA和MRA具有诊断价值。一旦确诊 ,应尽早手术治疗。     

A new variant of intra-abdominal hernia.

A new variant of intra-abdominal hernia is presented. Available evidence suggests that this type of intra-abdominal hernia may be more prevalent than previously reported. Patients suffering from crampy, intermittent abdominal pain whose routine radiographic gastrointestinal studies are unrevealing often are labeled as having psychogenic disorders. Three cases are present giving similar histories and routine findings in which mesenteric arteriography coupled with careful small bowel series has revealed a surgically curable lesion. Such patients should have judicious mesenteric angiography coupled with routine radiographic gastrointestinal studies in search of small intramesenteric herniae which are readily correctible.     

Diverticular disease of the cecum and ascending colon. A review of 881 cases

A total of 881 cases of diverticula of cecum and the ascending colon were reviewed, including 30 new cases at the authors' institution. The average patient age was 43.6 years. The preoperative diagnosis was correct in only 7 per cent of the cases. Appendicitis accounted for 68 per cent of the preoperative diagnoses. Even at the time of surgery, the diagnosis was correct in only 58.7 per cent. Carcinoma was incorrectly diagnosed in 37.2 per cent. Operative procedures varied markedly. Diverticulectomy was performed in 28.2 per cent of the cases, 3.6 per cent had invagination of the diverticula, and 37.6 per cent had right hemicolectomy. The overall mortality rate was 2.5 per cent. The authors advocate local resection of the diverticulum, when possible, and a right hemicolectomy or segmental resection when the diagnosis is in doubt or when local resection or invagination will jeopardize the ileocecal valve or the blood supply to the intestine.     

The “Urological” pancreatic cyst—A diagnostic enigma

A further case of pancreatic pseudocyst with the preoperative diagnosis of renal cyst is reported. A left nephrectomy and a resection of the tail of the pancreas were performed and the patient made a good recovery. There was no suspicion of abdominal trauma, biliary disease, or heavy alcohol intake. Cytology from aspirate revealed no signs of malignant cells. The amylase content was not determined. Despite IVP and selective renal arteriography a correct diagnosis was not obtained preoperatively.Five cases from the recent literature are presented and the diagnostic problems discussed.In some cases the diagnosis may be possible by determination of the amylase content of the cyst fluid and a selective arteriography of the superior mesenteric artery with its splenic and jejunal branches. In other cases preoperative diagnosis may remain enigmatic.     

Volvulus of the cecum and ascending colon

A review of twelve cases of volvulus of the cecum and ascending colon is presented. Such volvulus accounted for 0.8 per cent of all cases of intestinal obstruction and 10.5 per cent of all cases of intestinal volvulus. The clinical findings were those of low small bowel obstruction. In 50 per cent of the patients the involved bowel was viable and required only deflation and derotation. In the remaining patients right hemicolectomy or segmental ileocolectomy was carried out since the bowel was nonviable. The mortality for the entire series was 16.6 per cent.     

Giant cell arteritis manifesting as mesenteric ischemia

We report a case of giant cell arteritis in an 80-year-old woman who presented with chronic mesenteric ischemia to our vascular surgery service. Computed tomography, arteriography, and magnetic resonance angiography revealed long, smooth stenosis of the superior mesenteric artery and focal stenosis of the celiac artery. After the patient was found to have an elevated erythrocyte sedimentation rate and a positive temporal artery biopsy specimen, glucocorticoid therapy was initiated. Giant cell arteritis is a rare and easily overlooked cause of vascular insufficiency that can result in a devastating clinical outcome if not recognized before surgical therapy or other interventions are attempted.     

Angiographic diagnosis of bleeding Meckel's diverticulum in remission

The paper reports a case of Meckel's bleeding diverticulum which was diagnosed preoperatively using a selective arteriography of the superior mesenteric artery. The infrequent use of this instrumental test may be due to the small number of examples reported in the literature. In conclusion, the Authors underline that selective arteriography can be used with good results even in cases with hemorrhagic complications during the remission phase.     

Source of diagnostic pitfalls in renal sonography

In the evaluation of 116 renal masses 91 (80 per cent) were interpreted as cystic and 25 (20 per cent) as solid. Additional evaluation by arteriography and finally surgery showed that 3 of the 25 initially believed to be solid proved to be cystic. These three renal masses with internal echoes on ultrasound were found at surgery to be either collections of contiguous cysts or loculated cysts with calcification. These conditions are believed to represent a source of diagnostic pitfalls in renal sonography.