Endoscopic ultrasonograms in patients with Behçet's colitis

Abstract

Low-field extremity magnetic resonance imaging (lfMRI) is currently commercially available and has been used clinically to evaluate rheumatoid arthritis (RA). However, one disadvantage of this new modality is that the field of view (FOV) is too small to assess hand and wrist joints simultaneously. Thus, we have developed a new lfMRI system, compacTscan, with a FOV that is large enough to simultaneously assess the entire wrist to proximal interphalangeal joint area. In this work, we examined its clinical value compared to conventional 1.5 tesla (T) MRI. The comparison involved evaluating three RA patients by both 0.3 T compacTscan and 1.5 T MRI on the same day. Bone erosion, bone edema, and synovitis were estimated by our new compact MRI scoring system (cMRIS) and the κ coefficient was calculated on a joint-by-joint basis. We evaluated a total of 69 regions. Bone erosion was detected in 49 regions by compacTscan and in 48 regions by 1.5 T MRI, while the total erosion score was 77 for compacTscan and 76.5 for 1.5 T MRI. These findings point to excellent agreement between the two techniques (κ = 0.833). Bone edema was detected in 14 regions by compacTscan and in 19 by 1.5 T MRI, and the total edema score was 36.25 by compacTscan and 47.5 by 1.5 T MRI. Pseudo-negative findings were noted in 5 regions. However, there was still good agreement between the techniques (κ = 0.640). Total number of evaluated joints was 33. Synovitis was detected in 13 joints by compacTscan and 14 joints by 1.5 T MRI, while the total synovitis score was 30 by compacTscan and 32 by 1.5 T MRI. Thus, although 1 pseudo-positive and 2 pseudo-negative findings resulted from the joint evaluations, there was again excellent agreement between the techniques (κ = 0.827). Overall, the data obtained by our compacTscan system showed high agreement with those obtained by conventional 1.5 T MRI with regard to diagnosis and the scoring of bone erosion, edema, and synovitis. We conclude that compacTscan is useful for diagnosis and estimation of disease activity in patients with RA.     

Stratification of Gallstones in the Gallbladder

A clinical approach to the diagnosis of congenital cardiac malformations is described which the authors have found effective in exposing the important signs and their significance. Each available diagnostic method is evaluated separately before all data are correlated.

Clinical diagnosis based on history, physical examination, roentgenography and electrocardiography was 94 per cent accurate in a series of cases seen in office consultation and 90 per cent accurate in a series of hospital cases reviewed. The significance of the various signs and symptoms that are routinely searched for in the physical examination is discussed.

The salient points in the clinical diagnosis of the common entities are presented.     

Extracorporeal photopheresis for the treatment of severe,refractory steroid dependent pediatric Crohn's Disease

Crohn's disease is a chronic, inflammatory disease of the gastrointestinal tract, affecting both children and adults. Extracorporeal photopheresis (ECP) has been used in steroid dependent adults with moderate to severely active Crohn's disease, with response rates up to 50%, with up to 25% complete responses. A 12‐year‐old male patient had severe unremitting Crohn's disease for one year, despite treatment with anti‐inflammatory, immunosuppressive, and biologic agents. He failed elemental enteral nutrition and required total parenteral nutrition (TPN). A diverting colostomy for perforation was required. He required frequent hospitalizations and required homebound schooling. Endoscopy revealed severe inflammation and ulcerations of the entire colon. ECP was begun twice weekly for 4 weeks, then twice per week every 14 days for a total of 28 weeks. ECP was well tolerated and prednisone was gradually discontinued. He continued daily azathioprine and infliximab at 6 week intervals. TPN was weaned as enteral intake improved. Disease abatement allowed a return to school and normal activities. Endoscopy at completion of ECP course revealed normal upper tract, normal ano‐rectum, and decreased, although significant, colonic disease. This response has continued for at least 16 months since completion of ECP. We conclude that ECP is useful for pediatric patients with steroid dependent Crohn's disease and prospective evaluation is warranted. J. Clin. Apheresis 28:381–386, 2013. © 2013 Wiley Periodicals, Inc.     

Laparoscopic diagnosis and management of foramen of Winslow hernia - case report

Summary

Laparoscopy is a valuable tool in the diagnosis and management of abdominal pain. In this paper we report the first case of laparoscopic diagnosis and treatment of small bowel obstruction caused by a rare form of internal hernia, into the lesser sac through the foramen of Winslow.     

Enterotrophic effects of glucagon-like peptide 2 are enhanced by neurotensin

Combination therapy with enterotrophic agents may be useful in patients with the short bowel syndrome. The gut hormones neurotensin (NT) and glucagon-hke peptide 2 (GLP-2) are potent enterotrophic fattors when administered alone; however, their combined effects are not known. Using a GLP-2-producing tumor (STC-1), we determined whether administration of NT enhances the effect of GLP-2 on intestinal growth. Athymic mice were injected with STC-1 cells (6 × 10⁶) subcutaneously. Twenty-three days after STC-1 implantation, mice received either NT (300 μg/kg or 600 μg/kg) or saline solution (control) subcutaneously three times a day for 6 days. Two groups of tumor-free mice received either saline or NT for 6 days. At sacrifice, jejunum and ileum were collected, weighed, and analyzed for DNA and protein content. In the jejunum, NT combined with GLP-2 (from STC-1) increased weight, protein content (markers of mucosal hypertrophy), and DNA content (a marker of mucosal hyperplasia), compared to either NT or GLP-2 alone. In the ileum, the combination of NT and GLP-2 significantly increased weight and/or protein content compared to NT or GLP-2 alone. Administration of NT enhances the enterotrophic effects of GLP-2, augmenting hypertrophy of the entire small bowel and hyperplasia of the jejunum. The combination of NT and GLP-2 may be useful to enhance intestinal growth in patients with the short bowel syndrome. Supported in part by National Institutes of Health grants PO1 DK356O8, ROI DK48345, ROI AG10885, and T32 DK07633. Presented in part at the Surgical Forum of the American College of Surgeons, Chicago, Ill., October 12–17, 1997; and at the Thirty-Ninth Annual Meeting of The Society for Surgery of the Alimentary Tract, New Orleans, La., May 17–20, 1998.     

Small bowel obstruction following low anterior resection: the impact of diversion ileostomy

Background The incidence of small bowel obstruction following rectal cancer surgery has not been well documented in the era of sphincter-preserving surgery. This report aimed to study the incidence, aetiologies and outcomes of small bowel obstruction in patients after low anterior resection for rectal cancer. The factors that might affect the incidences of small bowel obstruction were analysed.Methods Consecutive patients who had undergone low anterior resection for rectal cancer from August 1993 to March 1999 were studied. Patients with unplanned admissions, with the diagnosis of small bowel obstruction, were reviewed. The aetiologies and outcome of small bowel obstruction were documented.Results Two hundred and fourteen patients were included, with a median follow-up time of 39 months; 22 patients presented with 30 episodes of small bowel obstruction, and operations were necessary in nine patients (40.9%). Malignant obstruction occurred in two patients (10.3%). Obstruction within 6 weeks of surgery (including closure of stoma) occurred in 13 patients (6.1%). Early obstruction occurred at a higher incidence in those patients who had had an ileostomy than in those who did not (9.1% vs 2.9%, P=0.048).Conclusion Small bowel obstruction following rectal cancer surgery occurred in 10.3% of patients. The majority of the obstruction was benign in nature. The presence of diversion ileostomy was associated with an increased incidence of early obstruction, and the use of loop ileostomy for proximal diversion should be further assessed.     

Laparoscopic diagnosis and treatment of intestinal obstruction

Background: Intestinal obstruction is a common reason for general surgical referral. The traditional approach has been conservative management, followed by laparotomy if conservative measures are unsuccessful. However, with the advent of minimally invasive surgery, the need for laparotomy for this common problem is being challenged.Methods: From May 1991 to April 2001, 167 patients underwent laparoscopy for diagnosis and/or treatment of intestinal obstruction. Average patient age was 62 years (range, 21–98). The site of obstruction was the stomach in seven patients, small bowel in 116 patients, and colon in 44 patients.Results: Laparoscopy successfully diagnosed the site of obstruction in all patients. In addition, 154 patients (92.2%) were successfully treated laparoscopically without conversion to laparotomy. Both intraoperative and postoperative complication rates were low (3.5 and 18.6%, respectively) and compared favorably with those of published reports.Conclusions: Intestinal obstruction can be approached safely and effectively by laparoscopy with the intent not only to correctly diagnose the patient but also to render treatment.     

Imaging bowel obstruction: a comparison between fast magnetic resonance imaging and helical computed tomography

AIM: To compare the accuracy of fast magnetic resonance (MR) imaging using the half-Fourier single shot turbo spin echo (HASTE) sequence with helical computed tomography (CT) in diagnosing bowel obstruction. MATERIALS AND METHODS: Prospective evaluation of 44 patients with clinical evidence of bowel obstruction was conducted using various investigations including HASTE MR and helical CT. MR was performed with a Siemens 1.5 Tesla MR Imaging System and CT was performed with one of two Siemens ARHP CT systems using helical technique. MR acquisition allowed data to be gathered in 6-10 minutes and no contrast media were administered. CT imaging consisted of consecutive helical CT through the abdomen and pelvis with oral and intravenous contrast medium used when indicated. Bowel dilation along with the presence and level of obstruction were determined. RESULTS: Twenty-eight patients had bowel obstruction confirmed at laparotomy or by radiographic assessment. Of these, 25 had small bowel obstruction and three had colonic obstructions. The obstruction was due to fibrous adhesions in nine patients, metastases or primary carcinoma in seven, Crohn's disease in four, hernias in two, and inflammation or abscess in two. Other causes of obstruction included lymphoma, intussusception and anastomotic stricture. The cause of obstruction was correctly diagnosed by CT in 71%, and by MR in 95% of cases. The sensitivity, specificity and accuracy for HASTE MR imaging was 95%, 100% and 96% respectively as compared to 71%, 71% and 71% for helical CT. CONCLUSION: Fast MR imaging using the HASTE sequence is more accurate than helical CT in diagnosing bowel obstruction.