Surgery For Peptic Ulcer Disease Research Articles

Laparoscopic management of benign gastric outlet obstruction: a case series with review of literature

Surgery for peptic ulcer disease has since long become a thing of the past, in the era of proton pump inhibitors. Today, it is difficult to believe that these were common operations about 6-7 decades ago. Such has been the impact of proton pump inhibitors (PPI), that, surgery for peptic ulcer has been relegated to the realms of history. However, even in present day, in some rare clinical situations, surgeons may have to resort to surgery for patients suffering from peptic ulcer disease. Herein, we present our experience of laparoscopic surgical management of one of those rare clinical scenarios related to severe peptic ulcer disease. The clinical condition in discussion is gastric outlet obstruction caused by severe peptic ulcer disease in the first part of duodenum. We identified 8 patients (7 males and 1 female) who underwent laparoscopic vagotomy with gastrojejunostomy for benign gastric outlet obstruction, at our institution, operated upon by a single surgeon, between 2004 to 2023. All patients had undergone oesophago-gastro-duodenoscopy (OGD scopy), and contrast enhanced computerised tomography (CECT) of the abdomen. The patients were analysed for age, sex, symptoms, pre-operative evaluation, morbidity/mortality and functional outcomes. They were also reviewed to examine the length of stay, length of procedure, complications and recurrent symptoms on follow-up.

Rise and fall of surgery for peptic ulcer disease

Earlier the treatment for peptic ulcer was surgery such as truncal vagotomy and drainage procedure. Recurrence after surgery and complications were common. It was because of our lack of knowledge about helicobacter pylori bacteria we used to blame factors such as lifestyle, other than infections causing peptic ulcer. It was due to two genius Australian doctors who identified the bacteria and the scenario was changed. Surgery for peptic ulcer gradually diminished dramatically after the development of H2 receptor antagonists and proton pump inhibitors. The surgery for complications of peptic ulcer such as perforations remain same but elective surgery for peptic ulcer drastically reduced. There was a time when after failed medical treatment for peptic ulcer patients were advised surgery or remain on cold milk and bread. These researches in medicine have alleviated human suffering from peptic ulcer disease. Patients of deep penetrating peptic ulcer used to weep with pain and treating clinicians also used to get frustrated for not getting ways to make patients painfree.

Comparison of POMPP Scoring System with PULP Score, Boey Score, and ASA Scoring Systems to Predict Mortality in Peptic Perforation

Perforated peptic ulcer represents the most frequent indication for emergency surgery for peptic ulcer disease. The mortality from perforated peptic ulcer remains up to 27%. We compare predictive score of mortality in perforated peptic ulcer (POMPP) scoring system with peptic ulcer perforation (PULP) score, Boey score, and American Society of Anesthesiologists (ASA) score to predict mortality. Hundred consecutive patients were operated for peptic perforation from May 2018 to May 2019 in our institute. For prediction of mortality, scoring was done by POMPP score, PULP score, Boey score, and ASA score. Comparative analysis of different score was done. Mean age was 40.7 years and male to female ratio was 32.3:1. Post-operative morbidity was 27% and mortality rate was 11%. Of the 10 patients of high POMPP score, 8 patients died (p value 0.000001) with accuracy of 80%. Receiver operating characteristic curve analysis showed that area under curve was 0.964 for POMPP score, 0.980 for PULP score, 0.960 for Boey score, and 0.906 for ASA score. The specificity of Boey score, POMPP score, and PULP score was 88.7%, 97.7%, and 100% respectively. Boey score had accuracy of 44.4% and PULP score had 100% accuracy in predicting mortality but it is complex with more number of components. POMPP score is based on objective data and its components are age and routinely measured values (blood urea nitrogen and serum albumin). It is simple and easily applicable scoring system for predicting mortality in peptic perforation peritonitis patients with accuracy of 80%.

Mortality and Health Care Utilization Among Medicare Patients Undergoing Emergency General Surgery vs Those With Acute Medical Conditions

Emergency general surgery (EGS) represents 11% of hospitalizations, and almost half of these hospitalized patients are older adults. Older adults have high rates of mortality and readmissions after EGS, yet little is known as to how these outcomes compare with acute medical conditions that have been targets for quality improvement. To examine whether Medicare beneficiaries who undergo EGS experience similar 1-year outcomes compared with patients admitted with acute medical conditions. This population-based, retrospective cohort study using Medicare claims data from January 1, 2008, to December 31, 2014, included adults 65 years or older with at least 1 year of Medicare claims who had urgent or emergency admissions for 1 of the 5 highest-burden EGS procedures (partial colectomy, small-bowel resection, peptic ulcer disease surgery, lysis of adhesions, or laparotomy) or a primary diagnosis of an acute medical condition (pneumonia, heart failure, or acute myocardial infarction). Patients undergoing EGS and those with acute medical conditions were matched 1:1 in a 2-step algorithm: (1) exact match by hospital or (2) propensity score match with age, sex, race/ethnicity, Charlson Comorbidity Index, individual comorbid conditions, claims-based frailty index, year of admission, and any intensive care unit stay. Data analysis was performed from July 16, 2018, to November 13, 2019. Partial colectomy, small-bowel resection, peptic ulcer disease surgery, lysis of adhesions, or laparotomy or a primary diagnosis pneumonia, heart failure, or acute myocardial infarction. One-year mortality, postdischarge health care utilization (emergency department visit, additional hospitalization, intensive care unit stay, or total hospital encounters), and days at home during 1 year. A total of 481 417 matched pairs (mean [SD] age, 78.9 [7.8] years; 272 482 [56.6%] female) with adequate covariate balance were included in the study. Patients undergoing EGS experienced higher 30-day mortality (60 683 [12.6%] vs 56 713 [11.8%], P < .001) yet lower 1-year mortality (142 846 [29.7%] vs 158 385 [32.9%], P < .001) compared with medical patients. Among 409 363 pairs who survived discharge, medical patients experienced higher rates of total hospital encounters in the year after discharge (4 vs 3 per person-year; incidence rate ratio, 1.31; 95% CI, 1.30-1.32) but had similar mean days at home compared with patients undergoing EGS (293 vs 309 days; incident rate ratio, 1.004; 95% CI, 1.004-1.004). In this study, older patients undergoing EGS had similarly high 1-year rates of mortality, hospital use, and days away from home as acutely ill medical patients. These findings suggest that EGS should also be targeted for national quality improvement programs.

Metachronous Skin Metastasis of Gastric Cancer: Case Report

An 86- year- old man, had undergone gastric surgery for peptic ulcer disease 40 years ago and he was diagnosed with gastric adenocarcinoma. Then he underwent a subtotal gastrectomy with regional lymphadenectomy, followed by Roux en Y gastrojejunostomy, and adjuvant chemotherapy. One and a half years later, the patient presented with a solid mass on his abdominal wall. Complete excision of the mass revealed a moderately differentiated adenocarcinoma consistent with the primary tumor of the stomach followed by fluorodeoxyglucose positron emission tomography (FDG PET) scan that showed hypermetabolic activity in the liver and the para-aortic lymph nodes, suggestive of distant metastasis.

Surgeon-driven variability in emergency general surgery outcomes: Does it matter who is on call?

BackgroundHospital-level variation has been found to influence outcomes in emergency general surgery. However, whether the individual surgeon plays a role in this variation is unknown. MethodsWe performed an analysis of the Florida State Inpatient Database (2010–2014), which is linked to the American Hospital Association's Annual Survey Database, including patients who emergently underwent 1 or more of 7 procedures (laparotomy, adhesiolysis, small bowel resection, colectomy, repair of a perforated gastric ulcer, appendectomy, or cholecystectomy). We used multilevel random effects modeling to quantify the amount of variation in mortality, complications, and 30-day readmissions attributable to surgeons. Patient clinical and demographic factors, as well as hospital-level factors, were introduced into the model in a forward stepwise fashion, and the percent of the variation attributable to surgeons was derived. ResultsOur study included 2,149 surgeons across 224 hospitals, with a total of 569,767 emergency general surgery cases. The overall unadjusted mortality rate was 3.8%, and the complication and readmission rates were 12.7% and 27.7%, respectively. Surgeon-level variation had the greatest impact on mortality, explaining 32.77% of the overall variability in mortality risk compared with 0.08% and 2.28% for complications and readmissions, respectively. Peptic ulcer disease operations were most susceptible to surgeon-level variation in mortality and readmissions, whereas appendectomies and cholecystectomies were least susceptible to surgeon-level variation for all outcomes. ConclusionsSurgeon-level variation contributes to a significant portion of mortality in EGS. This variation is most pronounced in surgery for peptic ulcer disease, a high-risk, low-frequency surgical condition. Programs to reduce mortality in emergency general surgery should address reducing variability in practice with attention to high-risk, low-frequency procedures.

Gastrojejunocolic Fistula Changing Trends in Management

Introduction: Gastrojejunocolic fistula (GJCF) is a rare, preventable and debilitating complication of surgery for peptic ulcer. It commonly follows posterior gastrojejunostomy without/with incomplete vagotomy for peptic ulcer disease. Over period of time, with advances in medical science the modalities used in diagnosis and the treatment have changed. GJCF is associated with high morbidity and mortality. The objective of this study was to analyze our experience in the management of GJCF. Materials and methods: Between 1993 and 2017, 13 patients presented with GJCF after surgery for peptic ulcer disease at our hospital for elective surgery. Data from the records of these patients was analyzed retrospectively. Weight loss, faeculant vomiting and diarrhoea were the common symptoms. Diagnosis of GJCF was made by barium enema, upper gastrointestinal endoscopy, colonoscopy and CT scan abdomen. All patients underwent surgery- single stage 9 patients, two stages 2 patients and closure of fistula with distal gastrectomy in 2 patients. Conclusion: GJCF should be considered as a diagnosis in patients presenting with one or more of the clinical symptoms- faeculent vomiting, chronic diarrhoea, weight loss after surgery for peptic ulcer. Diagnosis of GJCF has evolved for barium enema to colonoscopy and CT scan. Depending on the nutritional status of patient the trend in the surgery has changed from multiple stages to single stage surgery.

Tu1111 Surgery for Peptic Ulcer Disease in Sub-Saharan Africa

Tu1111 Surgery for Peptic Ulcer Disease in Sub-Saharan Africa

Diarrhea With Severe Weight Loss Secondary to Gastrocolic Fistula (GCF)

Introduction: Gastric resection for peptic ulcer disease has decreased over the past 2 decades and hence complications of surgery for peptic ulcer disease are seen less frequently in clinical practice. We report a case of a large GCF in a patient with a history of gastrectomy. Case Report: 54 year-old-female with a 30 pack year history of smoking, Billroth 11 gastrectomy for peptic ulcer disease and revision with a Roux-en-Y gastrojejunostomy for delayed gastric emptying presented with a 3-month history of severe weight loss and diarrhea. Her weight dropped from 130 lbs to 73 lbs. with passages of 10 to 20 watery pale stools a day, occurring 15 to 30 minutes after meals. She reported no melena or hematochezia nor vomiting. On examination, the patient was disheveled and emaciated (BMI 11.5). Vital signs were within normal limits. Mild periorbital edema was present. There was only mild abdominal tenderness and no organomegaly or ascites. There was 2+ pitting bilateral peripheral edema. Significant laboratory results: Complete blood count was normal. Basic metabolic profile was normal except for BUN 2 mg/dl, creatinine 0.2 mg/dl, albumin 1.5 g/dl, prealbumin 10 mg/dl, phosphorus 1.1 mg/dl. Stool specimen was negative. Gastroscopy revealed a large cleaned based gastric ulcer on the jejunal side of the gastrojelunal anastomosis with a severely stenotic jejunal orifice (1-2 mm opening); a large gastrocolic fistula (15 mm) which the scope easily traversed. Colonoscopy and ileoscopy were unremarkable except for the fistula which was identified in the transverse colon.The patient was placed on TPN and after 4 weeks underwent surgery with en bloc resection and primary anastomosis. Discussion: Gastrointestinal malignancies were reported previously as the most common causes of GCF. Recently, benign etiologies appear to be more common. These include complications of peptic ulcer disease and enteral feeding tubes. The most common presenting symptoms are diarrhea, weight loss and abdominal pain. Diagnosis is made by barium enema. Endoscopy are useful but may miss small fistulae. Treatment in most cases is surgical.Figure 1: Gastroscopy revealing a large cleaned base gastric ulcer with a 2-mm stenotic jejunal orifice and a 15-mm gastrocolic fistula.

Socioeconomic disparities in the operative management of peptic ulcer disease

Over the last 60 years, there has been a nationwide decrease in the number of operations performed for peptic ulcer disease (PUD). In contrast, the experience at our university-based safety net hospital (SNH) was that ulcer operations are still performed frequently. We hypothesized that differences in frequency of PUD operation may occur in hospitals that serve different patient populations. The purpose of this study was to evaluate our experience with PUD and compare it with national trends. We received institutional review board approval and performed this retrospective study of patients undergoing operation for PUD between January 2008 and December 2011. Patient records at 2 hospitals (a private community hospital and a university SNH) with similar admission numbers and geographic catchment were examined for PUD risk factors, Helicobacter pylori status, insurance/income status, type of operation, and surgical outcomes. A case-matched control group of medically treated patients were identified after primary diagnosis of PUD by endoscopy at the SNH. Univariate and multivariate analyses were performed. The total number of operations for PUD performed at the SNH was greater than those performed at the private hospital from 2008 to 2011 (142 vs 24; P < .001). The private hospital followed national trends over the same time period with a decrease in operations for PUD of approximately 93% between 1967 and 2008 (115 to 8 operations per year nationally and 119 to 6 at the private hospital). In contrast with the national and local private hospital experience, the number of operations for PUD at SNH increased from 27 per year in 1985 to 36 per year in 2008. Additionally, 43% of patients at the SNH had no insurance, and 61% resided in the poorest quartile of zip codes compared with the 3% uninsured patient rate at the private hospital for a similar group of patients. At both hospitals, most operations were emergent (range, 83-92%) and treated with omental patch (45%), gastric wedge resection (15%), vagotomy and antrectomy (19%), or vagotomy and pyloroplasty (14%). At the SNH, the H pylori infection rate was less (48% vs 83%; P < .001) and nonsteroidal anti-inflammatory drug (NSAID) use was greater (76% vs 63%; P < .01) in the 142 surgical patients compared with the 320 medical controls. Adjusted risk ratios demonstrated insurance status, NSAID use, and lower socioeconomic class were all equally predictive of operative ulcer disease when compared with medical controls. Our study provides 2 observations. First, patients of lower socioeconomic standing may have increased rates of complicated PUD owing to multiple medical factors and other factors related to healthcare. Second, surgical care for PUD retains a clinically important role within this patient population.

An 85-year-old male with abdominal pain and previous gastric surgery

An 85-year-old Caucasian male presented as an emergency to hospital with a 3-week history of increasing colicky abdominal pain, anorexia and constipation. He had undergone an operation for peptic ulcer disease over 30 years previously. On examination the patient had a distended abdomen, which was tympanic to percussion. An upper midline laparotomy scar was apparent. A clinical diagnosis of small bowel obstruction was made. A CT scan of the abdomen and pelvis was requested. Selected images of the portal venous phase CT examination of the abdomen and pelvis with oral and intravenous contrast are shown in Figure 1. What do they demonstrate? What is the differential diagnosis? Figure 1. Selected coronal, axial and sagittal images from a portal venous phase study of the abdomen and pelvis. (a) Thickened segment of distended small bowel with intramural gas (arrows), (b) intraluminal curvilinear focus of calcification (arrow), (c) intraluminal ...

Helicobacter Pylori Is Not the Predominant Etiology for Peptic Ulcers Requiring Operation

As the number of patients requiring operation for peptic ulcer disease (PUD) declines, presumed contemporary ulcer etiology has largely been derived from medically treated patients not subjected to surgery. The purpose of this study was to examine the specific causes of PUD in patients requiring surgery. Our Acute Care Surgical Service registry was reviewed for patients operated on for complications of PUD from 2004 to 2009. Emphasis was placed on individual etiologic factors for PUD. There were 128 patients (52% male, 81% white) who underwent emergency operation including: simple patch closure (n = 61, 48%); gastric resection (n = 22, 17%); gastric resection with vagotomy (n = 21, 16%); vagotomy and pyloroplasty (n = 18, 14%); or other procedures (n = 6, 5%). Complications necessitating operation were perforation (n = 79, 62%); bleeding (n = 29, 23%); obstruction (n = 12, 9%); and intractability (n = 8, 6%). Perioperative mortality was 12.5 per cent. Risk factors for PUD included tobacco use (50%), alcohol abuse (34%), and steroids (21%). Nonsteroidal anti-inflammatory use was confirmed in 68 (53%) patients. Of the 128 patients, 82 (64%) were tested for Helicobacter pylori, 33 (40%) of which were positive and 49 (60%) negative. Helicobacter pylori, thus, was the confirmed ulcer etiology in only 26 per cent of cases. Unlike contemporary series of medically treated PUD, Helicobacter pylori may not be the predominant etiologic factor in patients who experience complications requiring surgery. A "traditional" surgical approach with liberal use of vagotomy, not antibiotic triple therapy, may well be the preferred treatment consideration in such cases.

Osteoporosis in Men: Insights for the Clinician

Osteoporosis has finally been recognized as an important disorder in men. Men have osteoporotic fractures about 10 years later in life than women. Owing to increasing life expectancy, more fractures are predicted. Important risk factors for men include advancing age, smoking or chronic obstructive pulmonary disease, glucocorticoid therapy, and androgen deprivation therapy for prostate cancer. Other groups at risk for osteoporosis include those with alcohol abuse, men on enzyme-inducing antiseizure drugs, and those with malabsorption or history of surgery for peptic ulcer disease. History and physical examination will likely reveal secondary causes of osteoporosis. Some, but not all organizations, recommend screening for osteoporosis in men older than age 70. In the USA, The Department of Veterans Affairs recommends case finding rather than screening. Evaluation starts with bone mineral density testing by dual energy X-ray absorptiometry of the spine, hip, and in some cases forearm. A few laboratory tests can be helpful, including measurement of 25-hydroxyvitamin D. Most studies of osteoporosis therapy in men are small; but alendronate, risedronate, zoledronic acid, and teriparatide are FDA-approved to increase bone density in men with osteoporosis. A new potent antiresorptive agent, denosumab, increased bone density dramatically in men on androgen deprivation therapy and is approved for this indication in Europe. Recognition, diagnosis, and treatment of osteoporosis in men should lead to fewer fractures and probably fewer deaths.

The scars of time: the disappearance of surgery for pyloric stenosis

IntroductionThe changing pattern of both elective and emergency operations for peptic ulcer disease (PUD) has been well described but less is known about operations for pyloric stenosis (PS).MethodsData registration was...

A Blow-out

A 51-year-old man had symptoms that suggested a pair of common diagnoses, but in fact, a rare phenomenon was at work. He presented to the emergency department with a 5-day history of right-sided flank pain, right-sided lower chest pain, and cough with expectoration of yellow sputum. On review of systems, he reported that he had been experiencing fatigue and decreased urine output for 1 month. He had no history of dysuria, hematuria, or significant medical problems, aside from a previous surgery for peptic ulcer disease 10 years earlier.

Unusual Case of Dysphagia in a Male

Plummer Vinson Syndrome, a triad of dysphagia, esophageal web, and iron-deficiency anemia, is a rarely reported diagnosis in current literature. The exact etiology of the syndrome remains controversial, but it has been linked to complicated nutritional deficiencies, autoimmune disorders, and hereditary factors, and has a remarkably high female to male ratio. This paper describes an atypical case presentation in a 53-year-old male with a remote history of peptic ulcer disease surgery.

Trends and Outcomes of Hospitalizations for Peptic Ulcer Disease in the United States, 1993 to 2006

Despite progress in diagnosis and treatment, peptic ulcer disease (PUD) remains a common reason for hospitalization and operation. The purpose of this study was to quantify the time trends of hospitalizations and operations for PUD in the United States (US) since 1993. The Healthcare Cost and Utilization Project Nationwide Inpatient Sample is a 20% stratified sample of all hospitalizations in the United States. It was used to study hospitalizations with PUD as the principal diagnosis during 1993 to 2006, including details on ulcer site, complications, procedures, and mortality. Statistical methods included the chi test and multivariate logistic regression. The national estimate of hospitalizations for PUD decreased significantly from 222,601 in 1993 to 156,108 in 2006 (-29.9%), with a larger reduction in duodenal ulcers (95,552 in 1993 vs. 60,029 in 2006, -37.2%) than gastric ulcers (106,987 in 1993 vs. 86,064 in 2006, -19.6%). The inpatient mortality rate of PUD decreased from 3.8% to 2.7% during 1993 to 2006 (P < 0.001). Hemorrhage remained the most common complication (71.6% in 1993; 73.3% in 2006) but perforation had the highest mortality (15.1% in 1993; 10.6% in 2006). In comparison to 1993, patients hospitalized for PUD in 2006 more frequently had endoscopic treatment to control bleeding (12.9% vs. 22.2%, P < 0.001), similar use of surgical oversewing of ulcer (7.6% vs. 7.4%), less use of gastrectomy (4.4% vs. 2.1%, P < 0.001), and less use of vagotomy (5.7% vs. 1.7%, P < 0.001). In multivariate logistic regressions, the determinants of mortality were similar in 1993 and 2006. Hospitalizations for PUD decreased in the United States from 1993 to 2006, suggesting a decrease in the prevalence and/or severity of ulcer complications over this recent time period. Despite increased patient age and comorbidities, there has been a significant decrease in PUD mortality, a significant increase in the use of therapeutic endoscopy for bleeding ulcer, and a significant decrease in the use of definitive surgery (vagotomy or resection) for ulcer complications.

Management of Common Bile Duct Injury during Partial Gastrectomy

Injury to the common bile duct (CBD) during upper gastrointestinal surgery for peptic ulcer disease is a serious complication with an underestimated prevalence in light of the few cases reported in the surgical literature. Three cases of CBD injury were referred to a multidisciplinary specialized gastrointestinal unit for management over a 4-year period. Anomalous anatomy, adhesions, and potential duodenal shortening secondary to contracture all predispose the biliary ducts to intraoperative injury. The axial nature of the blood supply to the extrahepatic ducts and the tendency of bile itself to cause rapid collagen turnover and fibrosis, combined with the inflammation and subsequent fibrosis to the surrounding tissues caused by bile leakage, give the bile ducts a high propensity for stricture formation. Frequently presenting symptoms of CBD injury immediately after surgery include jaundice, elevated bilirubin values, elevated t-tube drainage, and symptoms of sepsis. The most common complaints noted in patients who present in a delayed manner are symptoms of cholangitis. Even when injuries are rapidly identified and corrected, the potential for lasting negative impact on quality of life is great in many cases. When CBD injury occurs, the pancreatic duodenal union can be concomitantly disrupted.

Signet-Ring Cell Carcinoma Arising in the Gastric Stump after Duodenopancreatectomy for Ductal Adenocarcinoma of the Pancreas: A Case Report

The development of malignancy in the gastric stump following surgery for peptic ulcer disease is well recognized. There are also few reports on carcinomas occurring after surgery for malignant gastric disease. However, carcinoma of the gastric stump after duodenopancreatectomy is extremely rare. We describe what we believe to be an unusual case of signet-ring cell carcinoma of the gastric stump developing at the anastomotic site 5 years after duodenopancreatectomy for ductal adenocarcinoma of the pancreatic head. We performed remnant gastrectomy and Roux-en-Y gastrojejunostomy as a curative resection. This experience clearly underlies that g astric stump carcinoma (GSC) may mimic metastatic disease recurrence leading to diagnostic confusion after surgery for malignancy. Although an increased risk of gastric stump carcinoma after pancreatoduodenectomy for pancreatic cancer has not been established, the possibility of such a complication should be kept in mind when evaluating patients after gastric resection who present with symptoms of metastatic disease recurrence years after the primary operation. Investigations should be independent of the entity of the primary disease or its localization, since GSC may well be amenable to surgical cure as demonstrated in the presented case. Outpatient follow up results of the last four years indicated no recurrence in this case.

Case 117: Actinomycosis of Left Kidney with Sinus Tracts

A 39-year-old Samoan man presented to the emergency department with fever, progressive weakness, and left flank pain of 1-month duration. For several months, he had also experienced progressive weight loss. There was no history of recent trauma, and he was not taking any medication. His medical history was notable for a large left groin abscess and left lower lobe pneumonia of unknown cause 1 year prior to the current admission. Furthermore, he had undergone exploratory laparotomy and gastric surgery for peptic ulcer disease approximately 10 years ago. Physical examination findings were positive for a tender firm mass in the left flank with no associated skin changes. Laboratory findings revealed an elevated white blood cell count of 18 x 10(9)/L. The urine cultures were negative. A computed tomographic (CT) image obtained 1 year prior to the current admission was unremarkable. CT of the abdomen and pelvis (section thickness, 5 mm) was performed after ingestion of 900 mL of 2% diatrizoate meglumine and diatrizoate sodium (Gastrografin; Bracco Diagnostics, Princeton, NJ). A 150-mL dose of iohexol (300 mg of iodine per milliliter) (Omnipaque; Nycomed, New York, NY) was administered intravenously at a rate of 4 mL/sec with a 70-second scan delay. Unenhanced CT images (not shown) did not reveal any areas of high attenuation.