Scout Film Research Articles

Intestinal atresia due to intrauterine intussusception: Analysis of 24 cases in Japan

We have presented two cases of intestinal atresia due to intrauterine intussusception and reviewed 22 Japanese cases collected through personal communication. Most of the infants were full-term and without other malformations; they passed meconium, even though the abdominal scout film suggested an ileal atresia. On barium enema, a normal size colon was frequently observed. At operation, the atresia in all cases was single, and cord or gap type, and their prognoses were excellent. A necrotic intussusceptum or polypoid protrusion was seen in the distal bowel. These facts strongly suggest that intrauterine intussusception may occur in a late stage of pregnancy, and cause the impairment of blood supply to the intestine. The presence of occult blood in the meconium is indispensable for the diagnosis of these types of intestinal atresias.

A laser localizer light for tomographic positioning.

The use of a wall-mounted laser localizer light which improves the speed and precision of positioning for fixed-fulcrum tomographic equipment is described. Unproductive scout films are eliminated.

PEDIATRIC SURGLCAL EMERGENCY AND ITS RADIOLOGICAL DIAGNOSIS

Meconium peritonitis is an aseptic chemical peritonitis caused by spill of aseptic meconium in the peritoneal cavity due to perforation of the gut during the last 6 months of the gestation and early postnatal period. It has grave prognosis and only 15 survivors had been reported in Japanese literatures prior to 1975.A case of fibroadhesive type of the meconium peritonitis in a five-day-old male infant was presented. He was born in June 2, 1974. No abnormalities were found until he was in the 6th day of life, when he began to vomit bile stained fluid. He became distended by the next day and was transfered to the Gunma University Hospital. The scout film on admission (Fig. 1) revealed, a round calcium fleck in the subhepatic area with distended small bowel gas shadows. At laparotomy performed on the day of admission, dense calcified fibrous adhesions were found throughout the abdomen. No free perforation could be found. The adhesion was dissected out in the right lower abdomen and a side-to-side anastomosis was carried out between the bulbous distended portion of the small bowel and the terminal ileum. Immediate postoperative course was uneventful and he was discharged on June 26. However, he was readmitted on 83rd p.o. day in another hospital with fever and jaundice and died of an acute yellow liver atrophy caused by post-transfusion hepatitis on the 88th p.o. day. Hepatitis B antigen was demonstrated by an orcein method in the liver of the autopsied material.

2. On the Quantatitive Standard of Plain Roentgenogram Finding in the Colonic Obstucution

35 cases of the mechanical obstruction of the large bowel (MOLB), 35 cases of the paralytic ileus secondary to the generalized peritonitis (PIGP) and 35 cases as the control were all reviewed looking for the characteristic findings on the preoperative scout films. Diagnosis of MOLB and PIGP were based finally on findings at the laparotomy.Degree of the large bowel distension (DLBD) of MOLB group separated considerably from the other 2 groups at 1.5. Thus this level was thought to be of importance for the diagnosis of MOLB. Furthermore, the actual width of the large and the small bowel were measured during laparotomy in 12 cases without the intestinal obstruction; a ratio between them was approximately 1.5; meanwhile degree of the small bowel distension had been usually above 1.0 in the small bowel obstruction. It was conclusively considered reasonable that DLBD as a criterion of MOLB should be 1.5 or more. The other important criterion for MOLB was decided that the fluid level in the large bowel (FLLB) should be demonstrated according to the pathophysiology of the intestnal obstruction. MOLB group could be divided into 3 subgroups such as 1) congenital origin 2) volvulus of the sigmoid colon 3) symptomatic obstruction by preceding lesions, particularly that of malignancy.The congenitally originated showed substantially the highest range; the obstruction due to malignant growth showed the lowest. The essential difference of these distribution was recognized easily by their pathologic process. Additional notes stated that incomplete dependency of FLLB on DLBD; significance of the barium enema study of the colon against the scout film of the abdomen.

X-RAY FINDINGS IN THE PEDIATRIC SURGICAL EMERGENCIES

The incidence of congenital atresia of the esophagus in generally quoted as 1 in 3, 000 live births. In majority, it is associated with a tracheoesophageal fistula. Prematurity and multiple severe congenital anomalies are the two most common causes of death in these infants.A case of Gross A type atresia of the esophagus associated with high jejunal atresia, jejunal perforation and christmas tree deformity of the distal intestine was presented.The patient, a seven-hour-old girl, was referred to the Department of Surgery, Gunma University Hospital, on March 23, 1974 because of increasing abdominal distention and recurrent cyanotic spells since birth. The up-right scout film of the distended abdomen on admission showed generallized flank opacity without intestinal gas. A Replogle catheter with radiopaque sentinel line was introduced but lodged in the upper third of the esophagus and could not be advanced.Upon entering the peritoneal cavity, a large amount of bilious ascites was gushed out. A markedly distended proximal segment of jejunum ended abruply 5cm. distal to the ligament of Treitz. The remaining small intestine was coiled as an “apple peel” around a narrow mesentery attached at the ileocecal junction. A rupture was found at the apex of the distended proximal blind end of the jejunum. The perforated blind end was resected and end-to-side anastomosis was carried out. A Stamm gastrostomy was performed and a jejunal trans-anastomotic feeding tube was introduced. The abdomen was closed with a tube drainage. Immediately postoperative course was complicated with apneic spells but jejunal tube feeding was started from third p.o.day. She did well thereafter and she weighed about 8Kg. at eight months of age. She is now waiting a definitive operation.

X-RAY FINDINGS IN THE PEDIATRIC SURGICAL EMERGENCIES

A case of neonatal Hirschsprung's disease in a 25-day-old female infant was presented. She had passed her first meconium stool about 48 hours after the normal delivery. Since then, the bowels had moved only every two or three days. She became distended on 21st day of life and began to vomit on 23rd day of life. The abdominal scout film revealed distended loops of small as well as large bowel with air-fluid levels and situs inversus totalis (Fig. 1).A gstrografin enema examination demonstrated a normal calibered rectum and dilated sigmoid and descending colon. There was a distinct caliber difference at the recto-sigmoid junction and spastic irregular bizarre contour changes were seen in the rectum (Fig. 2).Enemas failed to decompress and the emergency transverse colostomy was made. Her postoperative course was uneventful.

The role of radiographic skull examination in the emergency evaluation of intracranial expanding lesions following closed head injuries.

The authors reviewed a series of 100 closed head injuries which at carotid angiography were found to harbor acute expanding lesions requiring emergency intracranial surgery. — Plain skull films preceding the angiography proved to give information which was not significant for the diagnosis and selection of the side on which to perform angiography, while clinical signs proved to be more valuable. — It is concluded that in cases of acute closed head injuries, whenever emergency surgery may be anticipated, an additional time-saving procedure may be the omission of the X-ray examination of the skull, in favor of immediate carotid angiography, to be performed on the side indicated by the clinical symptoms, or starting on the right side in their absence. The only relevant radiological sign, i.e., the shift of the pineal calcification, may be visible, if present, on the AP. scout films of the angiography. — If no indication for emergency surgery follows the angiography, the X-ray examination of the skull can then be performed with complete ease and every technical refinement.

Enterocolonic Fistula From Swallowed Denture

<h3>To the Editor.—</h3> A 62-year-old white man could not find his partial dental plate one morning. His wife thought that the family dog had taken it and hidden it somewhere. A two-day family search failed to locate the missing denture. On the third day following the loss, the patient noted the onset of abdominal pain. A plain film, taken by the industrial physician at the patient's place of employment, showed the partial plate present "somewhere" in the abdomen. After another eight days, daily roentgenograms of the abdomen confirmed that the plate was not moving from its initial location. Meanwhile, his symptoms were minimal and consisted of vague and poorly localized abdominal distress. He was eating well, had no nausea or vomiting, and exhibited no problems with bowel habit. He ultimately sought further medical advice because the teeth were not shifting position. Admission scout film of the abdomen (Fig 1) at

Gallstone disease in Sweden versus Japan clinical and etiologic aspects

The clinical features of 100 consecutive patients operated on for gallstone disease in a northern Swedish hospital and a hospital in southern Japan were compared. In contrast to earlier studies no difference was found in the sex ratio of the two series. The age distribution of the two series differed markedly and after corrections were made for differences in the age distribution of the two populations at risk, the conclusion was drawn that gallstone disease does not affect old people in Japan as often as in Sweden. In the Swedish series there were somewhat more cases with one or a few stones in the gallbladder whereas there were a few more cases without gallbladder stones in Japan. Nonvisualization of the gallbladder at cholecystography was found more often in the Swedish series. This difference was partly due to the age difference of the two series, nonvisualization occurring most often in patients in the eldest age groups. In Japan gallstones could be demonstrated far more often on a scout film of the abdomen. This was attributed to the difference in the composition of the stones; the stones were found to contain more calcium bilirubinate and other calcium compounds in Japan. Stones in the bile ducts occurred significantly more often in Japan than in Sweden. The higher frequency with which dilatation of the common duct and pathologic values for alkaline phosphatase were found in the Japanese series was attributed to the larger extent in which gallstone disease involves the bile ducts in Japan. This difference had an effect on surgical practice; common duct exploration and reoperation for biliary duct stones were performed more often in Japan. Also probably related to this difference was the higher frequency of elevated values of urinary amylase. Finally, as expected, serum cholesterol levels were higher in Sweden than in Japan.

X-RAY FINDINGS IN PEDIATRIC SURGICAL EMERGENCIES

X-ray films of gastric rupture in the newborn infant were presented with a brief comment.Case 1 : 1-day-old girl (birth weight 2, 800g.). She developed marked abdominal distention and cyanosis immediately after birth. An up-right scout film of the abdomen revealed massive pneumoperitoneum (Fig. 1) and the absence of the intestinal gas. The diagnosis of the gastric perforation with intestinal atresia was made. A linear tear, 2 cm, was found along the greater curvature high in the fundus. Atresia of the intestine was not confirmed at surgery. The gastric rent was closed in two layers and abdominal cavity was drained. The patient died shortly after operation. Permission for autopsy was refused.Case 2 : 6-day-old boy (birth weight 3, 100 g.). There had been no difficulties with delivery and no gastric intubation or attempts at resuscitation. On the 6th day of life, he become dyspneic and developed abdominal distention. The plain up-right film of the abdomen revealed pneumoperitoneum. Laparotomy disclosed a 4 cm. linear tear along the greater curvature from the fundus to near the antrum. The rent was closed in two layers and abdominal cavity was drained. He expired on the 1st postoperative day. Postmortem examination revealed generalized peritonitis. The sutured areas in the stomach wall were intact.

VARIABLES AFFECTING THE PREPARATION OF THE BOWEL FOR RADIOLOGIC EXAMINATION

Data on 102 outpatients who underwent diagnostic x-ray examinations, of whom 50 were scheduled for barium enema and 52 for intravenous pyelogram examinations, were collected over a ten-week period in an attempt to determine what constitutes a properly prepared bowel. This data consisted of ratings (poor, fair, good, or excellent) of scoul and study films, of information gathered from telephone interviews conducted with outpatients a week or two postexamination regarding the patient's preparation for the examination, and of information gathered from the patient's medical records regarding personal and medical health status. A distribution analysis and two stepwise regression analyses were performed on this data. Stepwise regresssion analysis I included the ratings of ths scout films but not the study films while the opposite was true for regression analysis 2. These stepwise regression analyses selected the following variables as the best predictors of the ratings of how clean the bowel appeared on the x-ray: the amount of time enema water was retained, the patient's method of elimination, the number of enemas taken, the administering person's knowledge of enema technique, the patient's medication history, and the volume of enema water retatined. However, these analyses did not account for all of the variance of the ratings of the x-ray films. Several possible sources of the unaccounted variance were offered. Some interesting implications for an experiment concerning the variables that affect the preparation of the bowel emerge from the explanations of the unaccounted variance, as well as the positive findings of the stepwise regression analyses, the distribution analysis, and previous studies. Present and past findings point to the need for an experiment which: I) uses x-ray rating scales and raters whose reliability has been established, 2)systematically varies the administering person's knowledge of enema technique-with emphasis on the slow administration and sufficient retention of enema solution, 3) varies the type of rectal bowel-cleansing agent employed, and 4) controls other relevant varibles identified in this exploratory investigation.

Toxic megacolon in acute fulminant ulcerative colitis

Summary Among 150 patients having colectomy for ulcerative colitis at the University of Michigan Medical Center in the past ten years, toxic megacolon was present in twenty-eight. In almost half of these cases, the toxic megacolon developed within three months of the onset of ulcerative colitis. Perforation of the colon occurred in twelve patients (42.9 per cent). Only four cases were uncomplicated after operation and none of these had colonic perforations. Sepsis developed in all cases in which perforation had occurred, leading to death in seven instances. The mortality was 32.1 per cent. Early diagnosis of toxic megacolon can be achieved by repeated abdominal scout films in patients with acute fulminant ulcerative colitis. Prompt operation when toxic megacolon develops is advised to decrease the incidence of colonic perforation and the accompanying morbidity and mortality.

Nephrolithiasis Connected With Hydronephrosis of a Crossed Renal Ectopia

A case of nephrolithiasis occurred together with marked hydronephrosis of a crossed renal ectopia. The bizarre and confusing appearance of the scout film was the most interesting feature of this case. Very surprising is the fact that this patient lived to middle age with scarcely any subjective symptoms despite the proved and extensive damage to the urinary tract.

Radiographic diagnosis of ureteral involvement by metastatic breast cancer.

Our purpose is to describe rather characteristic radiographic findings in 24 women with breast cancer in whom periureteral metastases developed. The detailed clinical courses of these patients, including factors relative to the management of ureteral obstruction, have been described elsewhere (2). Clinical Material These cases are unselected. A review of the records of all patients with metastatic breast cancer has not been made, nor have routine excretory urograms been obtained in all patients with mammary carcinoma. The metastases in these patients were suspected clinically on the basis of signs and symptoms suggestive or diagnostic of disease in the urinary tract. There were two types of ureteral involvement in these 24 patients. In 12, metastases were confined to ureteral or periureteral sites (“isolated”), while in the others ureteral disease was a part of more extensive pelvic and abdominal involvement, arbitrarily termed “bulk” metastases. The radiographic appearance was almost the same in both groups. All patients with “isolated” ureteral metastases had signs or symptoms of urinary tract disease. Seven had pain, either flank or abdominal, while frequency, oliguria, and/or anuria were noted in 6. Of the 12 patients with “bulk” metastases, one was asymptomatic, while the others complained either of flank or abdominal pain, or of dysuria, frequency, polyuria or oliguria, later progressing to anuria. In some patients, long intervals elapsed between the diagnosis of the primary tumor and the ureteral metastases. Hydronephrosis secondary to ureteral metastases has been observed as long as one hundred ninety-eight months after diagnosis of the primary. In 21 of the 24 patients ureteral metastases developed more than one year after the diagnosis of breast cancer had been established (2). The terms ureteral and periureteral are used interchangeably. Pathological examination of those ureters studied revealed the process to be one of invasion of periureteral fibroadipose tissue and lymphatics (2). Radiologic Diagnosis In addition to the excretory and retrograde pyelographic examinations, all patients had chest films and all but one had at least one skeletal survey during the course of the disease. These diagnostic procedures as well as other less frequently employed ones, such as abdominal scout films, gastrointestinal or large bowel studies, yielded evidence both directly and indirectly of the nature and extent of the secondary deposits. Radiographic evidence of disseminated cancer was apparent in most cases by the time of the initial examination of the urinary tract. Symptomatic evidence of disseminated disease occurred in most, but not all cases by the time the signs and symptoms of the urinary tract disorder had developed. The radiological studies of the urinary tract often revealed incidental findings of significance.

Demonstration of small acoustic neuromas, using negative contrast medium with tomography.

The diagnosis of acoustic neuroma usually does not present a major problem to the radiologist. The bony changes produced in the region of the internal acoustic meatus are well known and can usually be delineated in films of the petrous bone, either in the standard projections or with the aid of tomography (1, 3). Further information may be gained by fractional pneumoencephalography, which also helps to increase the number of cases in which a positive diagnosis can be made with certainty (6). There still remains, however, a small but significant group of patients in whom the above investigations fail to provide a clear-cut answer as to the presence or absence of a tumor, in most instances because of its small size. This report describes an additional method of examining the region of the internal acoustic meatus. It has been used in effective delineation of small acoustic neuromas and so thoroughly visualizes the contents of the cerebellopontine cistern and acoustic meatus that a negative study effectively excludes the presence of a mass. Method The examination is carried out on the Massiot-Philips tomographic table, using the hypocycloid movement. A spinal tap is performed in the usual way, and the patient is then placed prone on the table with a small support under each shoulder to allow for full flexion of the head. The head is flexed until the canthomeatal line is perpendicular to the table-top, with the forehead resting on the table, and then rotated 15–20 degrees toward the side to be examined in such a way that the corresponding cerebellopontine angle cistern is slightly elevated (Fig. 1). The optimal degree of rotation varies; in general we have found that the shorter the internal auditory canal, the less the required degree of rotation. Once the head is positioned correctly it must be fixed by a clamp or some other means so that the position remains the same throughout the study. The tomographic table is tilted head-up to bring the posterior fossa to a slightly higher level than the cervical and upper thoracic spine. Tomographic scout films are taken to establish the plane of the internal auditory canal. Seven milliliters of air is then injected into the subarachnoid space. The air will rise into the cerebellopontine cistern on the side being examined and will remain trapped there. A minute or two after the injection, tomographic films are taken to cover a depth of approximately 10 mm on either side of the internal auditory meatus. If the patient is correctly positioned the cerebellopontine angle cistern, internal auditory meatus and canal, and the lateral aspect of the belly of the pons should be clearly demonstrated (Fig. 2).

Scrotal abscesses simulating inguinal hernias.

3 cases of scrotal abscesses caused by gas forming organisms, two of which were misdiagnosed as irreducible inguinal hernias are presented. History and physical findings strongly suggested hernia. Preoperative scout films revealed loculated gas shadows overlying the scrotal outline simulating bowel pattern. Attempts at reduction were of course, unsuccessful. Surgical exploration revealed no hernias, but scrotal abscesses caused by gas forming organisms. These three cases are presented to make the reader cognizant of this condition so that if confronted by a similar situation, he might more easily make a correct diagnosis.

Delayed opacification of a common bile duct stone after intravenous cholangiography.

The phenomenon of delayed opacification of gallstones following cholegraphy was described and investigated by Salzman et al. in 1959 (3). They found that most biliary contrast media are absorbed at the periphery of pigment stones, producing a rim of radiopacity. Opacification was demonstrated with iopanoic acid (Telepaque), iodoalphionic acid (Priodax), tetraiodophenolphthalein (iodophthalein), and iophenoxic acid (Teridax) (3). The phenomenon has not previously been described following iodipamide (Cholografin). Indeed, Salzman and Watkins state that delayed opacification does not occur following iodipamide, either in vivo or in vitro (3, 6). Case Report Mrs. F. L., a 69-year-old female, had a long history of rheumatic heart disease and chronic urinary tract infection with cicatricial urethritis. Eight years ago acute cholangitis developed. Roentgenograms showed multiple radiopaque gallbladder calculi. Cholecystectomy was performed, and a single opaque stone was also removed from the common duct. T-tube cholangiography ten days after surgery was normal. Over the next eight years, the patient had chronic heart failure with hepatomegaly, but liver function studies were normal. The present admission was prompted by two weeks of right upper abdominal pain, icterus, and dark urine. On examination the patient was thin, sick, jaundiced, and in heart failure. Bilirubin was 3.4 mg per 100 cc direct examination, and 1.6 mg per 100 cc indirect. Amylase and lipase were normal. SGOT was 95 sigma units (N = 35). Alkaline phosphatase was 12.3 Bodansky units, (N = 5). Prothrombin time was normal. The patient was treated for heart failure; the jaundice and pain fluctuated. On Day 6, a liver biopsy showed slight fatty change and minimal periportal inflammation. On Day 10, bilirubin was 5 mg per 100 cc total, and alkaline phosphatase was 19.8 B units. Nevertheless, cholangiography was attempted with 20 cc of 52 per cent meglumine iodipamide given intravenously over ten minutes. As expected, there was no visualization of bile ducts, and no stones were seen (Fig. 1). On Day 19, the jaundice had abated and the heart failure improved. Bilirubin was 1.2 mg per 100 cc total. Intravenous cholangiography was repeated. Scout films showed a common duct stone with a peripheral rim of calcification (Fig. 2). In thirty minutes the common duct was visualized and was dilated proximal to the stone (Fig. 3). On Day 20, common duct exploration was performed. A 1 × 2 cm dark stone was removed from the distal common duct. X-ray studies of the specimen showed a calculus with a characteristic shell of opaque contrast medium (3) (Fig. 4). Postoperative tube cholangiograms were negative. Recovery was complicated by heart failure and major bleeding from a duodenal ulcer. The patient eventually left the hospital in fair condition.

Rectal cholecystography.

In 1961, bornancini et al. (1) suggested rectal administration of cholecystographic media for visualization of the gallbladder. They found the technic was simple, did not require special preparation, was without side-effects, and resulted in good visualization of the gallbladder. Because of difficulties sometimes encountered in oral cholecystography, e.g., failures due to vomiting, ileus, inflammatory gastrointestinal disease, and the occasional reactions in intravenous cholecystography, a good, safe, alternate route of administration is highly desirable. Since the Bornancini publication, only a few investigators have evaluated their technic (2–4). The present study was undertaken to determine the effectiveness of the rectal administration of two cholecystographic agents, ipodate sodium (Oragrafin sodium) and ipodate calcium (Oragrafin calcium), and to determine the technic for optimum visualization. Materials and Method Cholecystographic Media: Ipodate sodium and ipodate calcium salts are heatsensitive, decompose at room temperature when in solution or suspension, and should be freshly prepared before administration. The enema packages supplied contained 6 g of the dry ipodate salt. Immediately prior to administration, tap water was added to the neck of the accompanying polyethylene “squeeze” bottle. The total volume of the reconstituted agent was 60 cc, representing a single adult dose, and was introduced into the rectum directly from this container. Patient Preparation: The examinations were performed after an overnight fast. A soapsuds enema was administered immediately before the rectal administration of the ipodate preparation by ward nursing personnel. Early in the study, a laxative, bisacodyl (Dulcolax), was included of the bowel preparation. This appeared to cause difficulty in retention of the rectal ipodate and was discontinued. Roentgenographic Examination: An abdominal scout film was obtained of every patient two hours after the instillation of the rectal ipodate, and films of the right upper quadrant were taken at four and six hours. When visualization of the gallbladder was unsatisfactory, further films were taken every two hours up to an additional six hours. Patient Selection: All patients studied were selected from the wards of the Orange County General Hospital. A total of 43 rectal cholecystographic examinations were performed. There were 25 male and 18 female patients. Ages ranged from thirty to eighty years, with an average of forty-seven years. All selected patients, except one, were free of hepatobiliary, colon, or renal disease. Pregnant patients and those with known iodine sensitivity were excluded from the series. The diseases for which the patients were hospitalized included active tuberculosis, emphysema, bronchopneumonia, lymphoma, gout, arteriosclerotic heart disease, peptic ulcer, diabetes mellitus, and hypertension. The order in which the two agents were assigned was randomized.

Gastric herniation as a complication of transverse colostomy.

Herniation of the stomach at the site of a transverse colostomy must be rare, for no reference pertinent to its occurrence could be found on a survey of the literature. The following case illustrates the problems encountered in the diagnosis of this entity and the difficulty of its differentiation from volvulus of the right colon. A 76-year-old white female was admitted on Feb. 8, 1952, in the early evening, with symptoms of abdominal pain, distention, progressive constipation, and weight loss. Blood had been noted in the stool on one occasion about a month previously. On physical examination loops of distended bowel were visible, bowel sounds were markedly reduced, and there was diffuse abdominal tenderness. Admission scout films of the abdomen indicated a low colonic obstruction, probably neoplastic, and two hours later a transverse colostomy over a glass rod was performed. The bowel was decompressed with a needle, but not opened until the following morning. At that time moderate amounts of gaseous, fluid, and fecal matter were obtained, with a decrease of abdominal distention. The patient's condition continued to improve until Feb. 13, when she complained of severe abdominal pain. Clinical examination showed gangrene of a loop of the large intestine over the glass rod and, in addition, an air-filled viscus (small intestine?) pushed up into the wound. From the scout films, which demonstrated a distended gas-filled viscus in the upper abdomen, a volvulus of the cecum was suspected. A barium-enema examination disclosed complete obstruction of the sigmoid with findings characteristic of car-cinoma. During the examination the gas-filled viscus increased in size and again was judged to represent an ectopic cecum with obstruction due to volvulus. Delineation of the full thickness of the viscus wall by gas was attributed to pneumoperitoneum resulting from the recent surgery. On re-operation, the herniation of bowel around the transverse colostomy was again noted but, when the incision was enlarged, the dilated viscus proved to be the stomach. This was returned to the abdominal cavity. The entire intestine, both small and large, appeared gangrenous or on the verge of gangrene, the result, apparently, of extensive thrombosis of all the mesenteric vessels. The stomach on its return to the abdomen was normal in color. A large constricting carcinoma was identified in the sigmoid. At this time the patient was almost in extremis, and the abdomen was closed. Death occurred shortly afterward.

Pseudoseparation of bowel loops: a fallacious sign of intraperitoneal fluid.

The separation of air-containing bowel loops on the supine plain film of the abdomen has, for many years, been an accepted radiographic sign of intraperitoneal fluid and more recently has been stressed as a sign of bowel wall thickening. While Nelson and Eggleston, in their excellent paper on mesenteric vascular occlusion, alluded to the possibility of intraluminal fluid giving the appearance of separated bowel loops, they offered no evidence or explanation. Intraluminal fluid can produce the appearance of abnormal separation of the walls of adjacent bowel loops. We will refer to this phenomenon as pseudo-separation. Our attention was directed to this sign when we encountered it frequently in patients having nonspecific abdominal pain. We even observed it in scout films of asymptomatic patients who showed anxiety concerning an impending examination such as intravenous urography, aortography, or gastrointestinal studies. Figure 1, A, demonstrates a case in which the scout film clearly shows “separation” of gas-filled bowel loops prior to a gastrointestinal examination. Figure 1, B, however, reveals that there is no separation between the barium-filled loops. The loops are truly adjacent, and the bowel wall is not thickened. The mechanism of this phenomenon is based upon the presence of fluid as well as gas in the lumen of the bowel. If air is layered over fluid in the bowel, the vertical x-ray beam will define only the margin of the air column and not necessarily the margin of the bowel wall (Fig. 2, A). Two pathologic conditions which give the identical appearance on the film are free fluid in the peritoneal cavity (Fig. 2, B) and adjacent loops of bowel with thickened walls (Fig. 2, C). Figure 3 demonstrates this phenomenon more vividly. Four balloons of equal size were taped together and submerged in water. This model simulates bowel surrounded by the abdominal tissues. The first two adjacent balloons were filled only with air, whereas the other two were filled two-thirds with water and one-third with air. The apparent but not real separation of the latter two balloons is marked. A similar experiment was conducted with a loop of cadaveric small bowel (Fig. 4). Note the apparent separation of the loops when the bowel was three-quarters filled with water compared to the real contiguity present when only air was instilled. The amount of fluid in the bowel must be relatively large in proportion to the amount of gas for this phenomenon to occur. The diameter of the gas column which rises to the upper level must be smaller than that of the fluid. No doubt this relationship is not uncommon. This does not occur uniformly in films of the abdomen in which gas is present in the small bowel because there is usually a larger volume of gas than fluid. When the radiologist suspects that intraluminal fluid is causing apparent separation of the bowel loops, he can obtain an upright film to rule out this possibility.