Intra-abdominal Diseases Research Articles

Tietze's Disease Predates 'Chest Wall Syndrome'

<h3>To the Editor.—</h3> The article "Chest Wall Syndrome: A Common Cause of Unexplained Cardiac Pain" by Epstein et al (241:2793, 1979) describes a symptom-sign complex in which neuromusculoskeletal derangements mimic cardiac disease. That the patient group was at a specialized tertiary care center may have contributed to the highly sophisticated, extensive, costly and (in the cases of the 12 patients described) perhaps unnecessary diagnostic evaluations the authors detailed. However, I was greatly interested in the article because of its neglect of an entity probably more commonly experienced in real-world community practice: peristernal perichondritis (Tietze's syndrome¹). In 1974, I described the first reported cases of Tietze's syndrome affecting the xiphisternal joint²and, in 1977, analyzed 24 cases of xiphisternal perichondritis.³The disease has protean manifestations and is a mimic of severe cardiac, pulmonary, intra-abdominal, and other diseases. Among our patients, who ranged in age from 18 to 72

Gallium Citrate Ga 67 Imaging in Noninfectious Interstitial Nephritis

Gallium citrate Ga 67 has been reported to be of value in the diagnosis of both malignant and infectious intra-abdominal diseases. The drug may also be taken up by mononuclear phagocytes in noninfectious tubulo-interstitial disease of the kidney. Positive renal scans from patients with these diseases either become negative or show decreased uptake following treatment. With further support of these findings, gallium citrate Ga 67 may become a valuable tool in both diagnosis and follow-up of noninfectious interstitial nephritis.

Diabetic truncal mononeuropathy--a new clinical syndrome.

Although diabetic mononeuropathy affecting the cranial and peripheral nerves is well recognized, there is little known or documented about diabetic mononeuropathy affecting the thoracic nerves, i.e., the truncal nerves. This series of 40 cases attests to its frequency; equal sex distribution; significance in differential diagnosis including coronary artery disease, intra-abdominal surgical diseases such as gallbladder pathology and appendicitis, pleurisy, and neoplasms. Truncal mononeuropathy has characteristics that differ from those of other diabetic mononeuropathies in that it is primarily sensory and typically not a first manifestation of clinical diabetes, whereas the other forms of diabetic mononeuropathy are primarily motor in effect and not infrequently may be the initial clinical presenting manifestation of diabetes. Finally, diabetic truncal mononeuropathy has a good prognosis.

Diseases of the urachus simulating intra-abdominal disorders

The urachus forms in early embryonic life as a tubular communication between the bladder lumen and the allantois. After birth the bladder descends and the urachus undergoes varying degrees of regression during which its lumen normally closes. Various diseases may affect the urachus. Their symptoms, signs, and pathologic anatomy are reviewed. A common feature of these conditions is partial reopening of the lumen of the regressive urachus. The distinction between congenital and acquired urachal diseases is made. Five cases of acquired urachal disease, observed in a department of abdominal surgery, are reported. It is emphasized that the symptoms and signs were suggestive of acute abdominal conditions caused by intra-abdominal diseases. Acquired urachal disease, causing a true acute abdominal condition, elicited by supervening complications, is described on the basis of the literature and the present series. Therapeutic principles are discussed, taking into account the possibility of malignant degeneration of the urachus and the high recurrence rate in acquired urachal disease.

Aortography in blunt abdominal trauma.

CATHERIZATION of the visceral branches of the abdominal aorta was first described by Biermann in 1951.¹Since that time the value of selective arteriography in the detection of a variety of intra-abdominal diseases has been repeatedly emphasized.^2-5This technique was first applied in patients with abdominal trauma by Norell⁶in 1957, thereby confirming the diagnosis of splenic rupture. Subsequent reports served to emphasize the value of this study in injuries of the kidney,^7,8spleen,^3,9and liver.^10,11Unfortunately, the precarious condition of many patients and the inconstant availability of special equipment and skilled personnel has limited the use of these studies to less urgent cases. Since selective arteriography involves catheterization of a single branch of the abdominal aorta, some knowledge of the presumed site of injury is necessary and its value as a screening technique is limited. In 1965, we undertook a study of aortography

Esophageal Acid Perfusion Test and a Gastroesophageal Reflux Test in Patients with Esophagitis

Summary Two new procedures helpful in diagnosing esophagitis have been studied. The first is infusion of hydrochloric acid into the esophagus to attempt to reproduce the spontaneous symptoms. The second is detection of gastroesophageal acid regurgitation by simultaneous measurement of intraluminal pressure and pH. One hundred and twenty-four subjects studied by these two procedures revealed the following: 81 had clinical, endoscopic, or radiographic evidence of esophagitis. Of these, 64 responded positively to acid perfusion and manifested acid reflux; 2 showed symptoms on acid drip but no regurgitation; 15 failed to respond to acid perfusion but showed reflux. Forty-three patients were asymptomatic. Of these, 3 demonstrated esophageal acid regurgitation; the remainder responded negatively to both tests. Of 93.6 per cent of patients showing a zone of increased pressure in the area of the hiatus varying from 1 to 5 cm. in length, 3.2 per cent revealed, in addition, sustained elevation of intraesophageal above mean fundic pressure throughout the entire length of the esophagus, presumably due to esophageal spasm. These latter patients had symptoms referable to the esophagus, reacted to esophageal acid perfusion, and showed acid reflux. In all patients not manifesting diffuse increase of intraesophageal pressure, neither the height nor the length of the zone of increased pressure at the hiatus, nor the magnitude of the decrease between fundic and intrathoracic end-expiratory pressure was correlated with presence or absence of acid reflux. These findings show that gastroesophageal reflux occurs in most patients with esophagitis, and they support the hypothesis that this reflux plays a dominant role in the pathogenesis of the disease. Furthermore, both tests proved useful in differentiating esophagitis from other intrathoracic and intraabdominal diseases, especially angina pectoris and peptic ulcer. However, the mechanisms whereby gastric contents are normally prevented from entering the esophagus and the nature of the defect which permits such regurgitation remain obscure.

Pneumonic Densities Obscured by the Cardiac Shadow

From a survey of an extensive series of roentgenographically proved pneumonias, it has become manifest that areas of pneumonic density may sometimes be obscured by the cardiac shadow on the roentgenogram. Since approximately two-thirds of this shadow lies on the left side of the thoracic spine, it overlaps the mesial and lower portion of the left lung in the routine postero-anterior view. An analysis of the structures portrayed on the roentgenogram of this area reveals a super-imposition of the lung itself with its bronchovascular markings, the ribs and the costovertebral articulations, and the heart shadow. In the normal subject, this area should appear as a fairly homogeneous shadow. Any variation or change in the uniformity of the density should arouse suspicion of the presence of a pneumonia in this region. Further radiological examination with left oblique or left lateral projections should make it possible to rule out or confirm such a process, which might otherwise be overlooked (Figs. 1 and 3). The fact that a pneumonic process may be obvious roentgenographically in one portion of the chest does not rule out the possibility of another pneumonic lesion hidden behind the cardiac shadow in the left lung (Fig. 2). The recognition of a pneumonia obscured by the cardiac shadow is an important factor in the differential diagnosis of intra-abdominal and intrathoracic diseases, for it may prevent needless operative exploration, as in Case 1, reported here. Meningeal irritation may be of pneumococcal origin, and here, too, a complete pulmonary examination with multiple views is necessary. A pneumonia may be present in the left lower lung field with the mesial portion extending behind the heart. In spherical pneumonic consolidations this creates a curious half-moon effect. The use of an over-exposed film technic will demonstrate this satisfactorily (Fig. 4). Case 1: Pfc. H. D. M., aged 21, entered the Station Hospital, A.A.F.T.S., Sioux Falls, South Dakota, on April 8, 1943, with nausea and vomiting, pain in the epigastrium, and tenderness in the right abdominal quadrant. A tentative diagnosis of appendicitis was made and the patient was admitted to the surgical service. Cough and expectoration were noted and physical examination revealed dullness and fine râles over the left base posteriorly. The temperature was 103.2°, pulse 118 and respirations 22. X-ray examination of the chest, April 8, 1943, disclosed a pneumonic density in the left lower lobe, obscured by the cardiac shadow in the posteroanterior view, but visible on oblique and lateral projections. The patient was transferred to the medical service and a diagnosis of lobar pneumonia was made. A blood count taken the same day showed 22,400 white blood cells, with 93 per cent polymorphonuclears and 7 per cent lymphocytes. No significant changes were observed on urinalysis. Sulfadiazine therapy was administered and resolution of the pneumonic process progressed satisfactorily.

THE SURGICAL SIGNIFICANCE OF THE ABDOMINAL REFLEXES

The diagnosis of acute intra-abdominal diseases has taxed the ability of the internist, pediatrician and surgeon alike. The literature on the subject is voluminous, but most writers have not stressed the signs which do not require the assistance of the laboratory. Any symptom that can be elicited at the bedside is a welcome aid to the diagnostic armamentarium. The cutaneous abdominal reflexes have not received their proper place as a valuable aid in the diagnosis of acute intra-abdominal disease. The literature on this topic is scant. Most writers have dealt with hyperesthesia, but the contraction reflex has been singularly omitted. Smith¹is an outstanding exception. The neurologists, such as Monrad-Krohn²and others, spoke of abdominal reflexes and did not include hyperesthesia, whereas, surgeons, such as Robinson,³Logat⁴and Cope,⁵captioned their articles abdominal reflexes and described hyperesthesia of the skin, but failed to mention the