Patterns of calcifications and cholangiographic findings in hepatobiliary tuberculosis

The radiologic findings on conventional examinations (plain films and cholangiograms) in a large group of patients with proven hepatobiliary tuberculosis are reviewed. The plain film findings of large chalky and confluent hepatic calcifications or nodal-type calcifications along the course of the common bile duct are suggestive of hepatobiliary tuberculosis. Small, discrete, scattered calcifications may be mimicked by histoplasmosis but can be differentiated from hepatobiliary tuberculosis. Obstructing defects seen on cholangiography are indicative of tuberculosis when adjacent calcifications are present. The patterns of liver calcifications could provide a clue to the diagnosis of hepatobiliary tuberculosis and its differentiation from liver calcifications of various other etiologies.     

Wireless capsule endoscopy detects small bowel ulcers in patients with normal results from state of the art enteroclysis

BACKGROUND: Wireless capsule endoscopy (WCE) is a new technology for small bowel imaging. AIM: To report our initial experience with sensitivity of high quality enteroclysis in patients with small bowel ulcers detected by WCE. METHODS: Medical records of all patients referred for WCE from December, 2001 to April, 2002 at our institution were reviewed. All patients had negative upper and lower endoscopies and small bowel barium studies before WCE. RESULTS: There were 40 patients (19 female, mean age 57.3 yr) during this study period. Three patients had multiple small bowel ulcers detected by WCE. One with ileal ulcers and abdominal pain had an enteroclysis at another hospital before WCE. Review of the study at our institution showed that it was of excellent quality and was normal. Two patients with chronic iron deficiency anemia had multiple small bowel ulcers and were referred after WCE for a repeat small bowel barium study by biphasic enteroclysis performed by experienced GI radiologists. The radiologists were told in advance of the WCE findings. Both studies were considered technically to be of perfect quality. Despite this, both studies were negative. All 3 patients improved after therapy for Crohn's disease. CONCLUSIONS: Our data indicates that WCE may be more sensitive for small bowel ulcers than the best enteroclysis available.     

Surgery for chronic pancreatitis: cross-sectional imaging of postoperative anatomy and complications

OBJECTIVE: Surgery is increasingly undertaken for intractable chronic pancreatitis. We evaluated the postsurgical anatomy and complications of surgical options including Whipple, Puestow, Frey's, and Beger's procedures. CONCLUSIONS: Knowledge of postsurgical anatomy is important to avoid misdiagnosing expected anatomy as complications on CT examinations. It is important to carefully assess the upper abdominal arteries to detect subtle but potentially lethal complications.     

Technical refinements in enteroclysis

As the primary method of investigating the small bowel, enteroclysis remains a technique in evolution. Technical refinements have made the examination faster to perform, better tolerated by patients, and easier to interpret. More recently, its essential principle of volume challenge has been combined with the tremendous advantage of CT cross-sectional imaging with multiplanar reformatting to give rise to the exciting new techniques of CT enteroclysis and MR enteroclysis (see separate reviews in this issue). Through improvements in methodology and advancements in technology, the future of enteroclysis looks bright indeed.     

Disconnected pancreatic duct syndrome: imaging findings and therapeutic implications in 26 surgically corrected patients

PURPOSE: The lack of ductal continuity between a viable pancreatic tissue and the gastrointestinal tract results in the disconnected pancreatic duct syndrome (DPDS). The purpose of our study is to describe accurately the imaging features of CT scanning and endoscopic retrograde pancreatography (ERCP) that define the DPDS. METHODS: We conducted a retrospective analysis of the computed tomography (CT) and ERCP examinations in 26 consecutive patients with surgically proven disconnected pancreatic ducts treated over a 5-year period at our institution. Two abdominal radiologists concurrently defined the imaging features (presence and size of fluid collection along the course of the pancreatic duct, upstream enhancing pancreatic parenchyma, and ERCP abnormalities) via consensus for both exams. Patient demographics, etiology of pancreatitis, surgical treatment, initial CT interpretation, and the delay between symptom onset to correct diagnosis were recorded. RESULTS: A discrete, intrapancreatic fluid collection (average size = 27 cm2 (range, 4-74 cm2) along the course of the main pancreatic duct with upstream viable pancreatic parenchyma was identified by CT in 26 cases. ERCP showed ductal obstruction at the level of the intrapancreatic fluid collection in all patients with extravasation of contrast in 14 (54%). All patients were treated by operation: 15 (58%) by internal drainage into a Roux-en-Y limb of jejunum and 11 (42%) by distal pancreatic resection. No prior CT interpretation correctly identified DPDS. The average delay between symptom onset and definitive diagnosis was 9.3 months (range, 3-36 months). CONCLUSIONS: A discrete intrapancreatic fluid collection along the expected course of the main pancreatic duct with viable upstream pancreatic parenchyma suggests the diagnosis of DPDS. ERCP findings of ductal obstruction at the level of this fluid collection with or without contrast extravasation confirm this diagnosis. Treatment is surgical and requires either internal drainage or distal pancreatic resection for complete resolution.     

Efficacy of venous reconstruction in patients with adenocarcinoma of the pancreatic head

Pancreaticoduodenectomy is often avoided in patients with portal or superior mesenteric venous involvement due to the perception that venous resection is complex, morbid, and carries a poor longterm survival. Our recent experience using state-of-the-art imaging and strict resection criteria show that venous reconstruction increases operative time, transfusion requirements, intensive care unit stay, and total hospital length of stay, but has no significant impact on operative morbidity rates, mortality rates, or the incidence of positive histologic margins. Kalpan-Meier life table analysis shows similar survival curves when compared to a contemporary cohort of patients who do not undergo venous reconstruction. Presented as an abstract at the Americas Hepato-Pancreatico-Biliary Association Meeting, Miami Beach, Florida, February 28–March 1, 2003.     

State-of-the-art barium examination in opportunistic esophagitis

This report presents a comparison of state-of-the-art esophagography and endoscopy in the diagnosis of pathologically proven esophagitis. The modern multiphasic esophagogram is shown to have a sensitivity of 92% for the detection of opportunistic esophagitis in the immunocompromised patient. State-of-the-art esophagography provides a sensitive and inexpensive method for investigating patients in whom opportunistic esophagitis is suspected and for monitoring their response to therapy.