Ninth Intercostal Space Research Articles

Massive bleeding from esophageal varices is an emergency situation which carries a substantial mortality rate. Until recently the prognosis was worse than for coronary occlusion or cancer. Modern therapy has improved survival, but an accurate diagnosis is essential. Usually demonstration of varices is tantamount to localization of the bleeding point. Making the diagnosis under duress, however, is fraught with well known difficulties. Contrast radiology of the esophagus, esophagoscopy, and splenoportography are wanting in simplicity, accuracy, and safety. The present essay describes a rapid, inexpensive approach for the accurate evaluation of portal circulatory dynamics. The technic affords a means for comparing the characteristics of venous circulation from spleen to liver with those from spleen to heart. Methods and Materials The procedure was developed in animals and subsequently employed as a preliminary to splenoportography. Results proved to be sufficiently distinctive to warrant the use of this approach in the initial appraisal of massive bleeding. Complete portability of apparatus allows the examination to be done anywhere within a hospital, at the bedside as well as in a suite for special studies. The test may be completed in ten minutes with ease. The technic makes use of a dual isotope detection-recording system such as that used for radiorenograms (Fig. 1). This consists of two scintillation detectors, utilizing 1 × 1-inch thallium-activitated, sodium iodide crystals, with 36° flat-field collimation and a minimum of 1 inch of lead side shielding. Two balanced, precision rate meters are operated at 30 K maximum response with time constants of 0.5 second. The linear chart recorders run at 12 inches per minute. One probe is centered over the liver in the mid-clavicular line, halfway between the upper limit of liver dullness and the right costal margin. In addition to the hepatic blood pool this detector “sees” the retrohepatic vena cava. The probe should be directed 5° laterally to avoid incorporating the coronary vein of the stomach in the field of response. The second probe is centered over the midsternal line, 5 cm. caudal to the angle of Louis. This detector “sees” the lower esophagus as well as the cardiac blood pool. Both detectors are adjusted at a distance of 7 cm. from the skin to the crystal. Percutaneous splenic puncture is made with a 2-inch, 22-gauge needle via the ninth intercostal space in the posterior axillary line. Only a few cubic centimeters of local anesthetic are required, and shallow breathing is permitted throughout the study. Approximately 30 µc of tracer in 0.5 to 1.0 c.c. volume is adequate for the determination. Although any compound with a gamma emitter may be used, radioiodinated Hippuran has been utilized because of its short biological half-life. Results Results of the more than 40 examinations completed thus far have been categoric, allowing the allocation of each study to one of five groups.

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