Upper Gastrointestinal Studies Research Articles

Surgical treatment of malignant esophagotracheal fistulas

Malignant esophagotracheal fistulas represent the fatal evolution of esophageal cancer. Since October 1974, 18 patients were seen who had confirmed esophagotracheal fistula, and in half of these patients, the fistula was the revealing symptom. Upper gastrointestinal studies (using hydrosoluble dye) and bronchoscopic examination confirmed the diagnosis, which was already strongly suspected in 16 of the patients due to the specific nature of the cough triggered by swallowing. The average age of the patients was 57 years, (range, 32 to 78 years). In 12 patients, the nutritional repercussions were moderate, and in only 6 patients, were the bronchopulmonary consequences serious. Therapeutically, we adopted a palliative surgical attitude since the physical and psychological condition of these patients was considered fatal the month after discovery of the fistula. In addition, the results of intubation were uncertain and transitory. Our surgical methods evolved in three stages: first, we performed bipolar exclusion of the esophagus coupled with gastrostomy (four patients), second, we performed retrosternal coloplasty (five patients), and third retrosternal gastroplasty with drainage of the inferior portion of the esophagus by Roux-Y jejunal anastomosis (six patients). The latter technique was inspired from that described by Kirschner in 1920. It is moderately aggressive and has the advantage of dealing with several objectives: exclusion of the fistula, reestablishment of normal alimentation, drainage of the inferior portion of the esophagus, and permitting postoperative radiotherapy. In our series, when only the patients who underwent coloplasty or gastroplasty were considered, 3 of 11 died, and the longest postoperative survival times were 16 and 23 months. Regarding gastroplasty alone, our results were in agreement with those in the literature. In the 19 patients who underwent gastroplasty, the operative mortality was 31.5 percent and the average length of survival was 9 months. Six patients survived from 8 to 26 months. Therefore, this “last resort” surgery seems legitimate in light of the fact that the results are sometimes superior to those of radical curative surgery for extirpative esophageal cancer.

Radiographs obtained during upper gastrointestinal fluoroscopy. Adequacy and comparison to postfluoroscopy images.

The usefulness of full-size radiographs obtained with the overhead tube following fluoroscopy was evaluated based on an analysis of 306 biphasic upper gastrointestinal studies that included follow-up postfluoroscopy views. In 32 studies with abnormal findings, the postfluoroscopy images were normal. In one case, the postfluoroscopy images revealed an abnormality not seen on spot views. The confidence levels rose in only 19 cases (6.2%) when postfluoroscopy images were used. In the appropriate setting, routine postfluoroscopy views after an upper gastrointestinal series are of little value. Nonetheless, in a teaching hospital, these images should be obtained when fluoroscopy is performed by junior residents.

Diagnosis of Intra-abdominal Abscess

To the Editor.— I read the article by Joseph T. Ferrucci, Jr, MD, and Eric vanSonnenberg, MD (1981;246:2728), regarding radiological diagnosis and treatment of intra-abdominal abscesses. They reported 90% to 95% rates of true-abnormal and truenormal accuracy. I have treated a patient with hypertension and renal failure who had a weight loss of 45 kg and abdominal pain. A series of six upper gastrointestinal studies, three barium enema examinations, three computed tomographic scans, laparoscopy, and abdominal aortography all failed to yield a diagnosis. A third surgical opinion suggested laparotomy, and a 2-L abdominal abscess at the site of an intestinal perforation was found. The patient eventually died. The editorial comment of Charles B. Clayman, MD (1981;246:2727), reiterating that ultrasophisticated diagnostic methods should not unduly influence a clinical decision is affirmed. Although helpful and occasionally dramatic findings can be achieved with new techniques, clinical evaluation and determination are still necessary.

Double-contrast esophagrams. The prone technique.

The authors describe a simple method for obtaining double-contrast images of the lower esophagus with the patient in a prone position. This technique has a high success rate, allows repeated imaging, and is easily incorporated into routine upper gastrointestinal studies. Diagnostic double-contrast studies were obtained in 78% of 28 patients. Ten abnormalities, including a Mallory-Weiss tear, were demonstrated. Single-contrast esophagrams, performed immediately afterwards, demonstrated only six abnormalities.

Case 5-1981

Presentation of CaseA 56-year-old man was admitted to the hospital because of hypoglycemia.There was a long history of alcohol abuse, with delirium tremens and hepatic disease. Eight years before admission a left pleural effusion developed, and a diagnosis of pulmonary tuberculosis was established. Chemotherapy was administered for two years, with questionable compliance. Four months before entry an x-ray film of the chest showed a nodule, 4 cm in diameter, in the right lung. An upper gastrointestinal study, an ultrasound study of the pancreas, and a liver-spleen scan were negative. The patient continued to imbibe large volumes of alcoholic . . .

Causes of error in gastrointestinal radiology. I. Upper gastrointestinal examination.

This paper explores the causes of errors on upper gastrointestinal studies. Of 129 ulcers and neoplasms seen endoscopically, 14 were unreported radiologically, representing false negative errors. The most common type of error was failure to note a lesion rendered poorly visible by an inadequate examination. Contributing technical failures included insufficient films, poor coating, poor compression films, retained food and secretions, and badly exposed films. Perceptive failures included both misinterpretation and failure to note a lesion. Among 10 false positive errors, barium between distorted folds simulating an ulcer occurred most commonly.

Preliminary abdominal films for gastrointestinal examinations: how efficacious?

A prospective study to evaluate the efficacy of preliminary abdominal films for colon and upper gastrointestinal examinations was carried out on 733 patients. The preliminary film was found to be cost effective and useful in predicting adequacy of patient preparation for colon examinations but not for upper gastrointestinal studies. Significant diagnostic information that could potentially contribute to the patient's care was present in 8.4% of the cases. No contraindications to contrast examinations were found.

Angiographic pattern of giant hypertrophic gastritis (Menetrier's disease)

Since Menetrier's classic description of giant hypertrophic gastritis (GHG) in 1888 there have been a number of reports concerning pathological and radiological patterns of this illness (Jeffries, 1978; Chusid et al., 1964). Clinically it has been established that hypoproteinaemia can occur in these patients because of excessive intraluminal losses of plasma protein (Schindler, 1963; Citrin et al., 1957; Overholt and Jeffries, 1970). Patients with GHG may present with epigastric pain, vomiting, fluid retention or even gastrointestinal bleeding. Carcinoma has been reported as appearing in the follow up of cases of GHG (Chusid et al.., 1964; Rubin and Fink, 1967). Although the enlarged mucosal folds can be demonstrated at upper gastrointestinal studies, and the findings are very suggestive of GHG, only a full thickness surgical biopsy will confirm the diagnosis (Schindler, 1963). The angiographic pattern of GHG has not been described, so far, and we think that angiography may be useful in the diagnosis and follow-up of this disease. The present case illustrates the angiographic aspect of an enlarged gastric mucosa because of GHG without malignant changes in the hope of facilitating early diagnosis and follow up. A 60-year-old man was admitted with a three-year history of epigastric pain, nausea, vomiting and episodic haematemesis and melaena. A radiological examination of the upper gastrointestinal tract, three years before, reportedly had shown a non-specific enlargement of gastric mucosal folds. Admission clinical examination revealed a tender abdomen and slight peripheral oedema. Vital signs were stable. Laboratory tests showed slight anaemia and hypoproteinaemia.

CONGENITAL PERITONEOPERICARDIAL DIAPHRAGMATIC HERNIA IN THE DOG AND CAT: A LITERATURE REVIEW AND 17 ADDITIONAL CASE HISTORIES

A systematic description of the history, clinical and radiographic signs, and clinical sequelae in 13 dogs and four cats with congenital peritoneopericardial diaphragmatic hernia (CPDH) seen over ten years is presented. The predominant signs were gastrointestinal and respiratory. The animals were 8 weeks to 10 years old. Eight of the 13 dogs were male; the four cats were female. Weimaraners were 30.8 percent of the affected dogs, but only 1.1 percent of the hospital population during the ten years reviewed. There were concurrent umbilical hernias in four dogs, congenital heart disease in two dogs, and sternal deformities in six dogs and one cat. Twelge of the 13 dogs and two of the four cats had survey radiographs. Superimposed diaphragmatic and caudal heart borders were seen in nine of the 12 dogs and both cats. Abnormal soft‐tissue gas or double soft‐tissue densities in the pericardial sac were seen in 11 of the 12 dogs and the two cats. Upper gastrointestinal studies, pneumoperitoneography, thoracic tomography, and right ventricular angiography were special studies used to evaluate CPDH. Surgical correction was successful in nine of 11 dogs; signs remained in two dogs. The longest postoperative survival was 6.5 years. A 14‐week‐old English Setter without surgical correction of its CPDH or pulmonic stenosis was free of clinical signs of either disease for 2.5 years. Twenty‐five reports of CPDH from 1960 to 1979 are reviewed.

Benign duodenocolic fistula due to duodenal diverticulum: report of two cases.

Two cases of benign duodenocolic fistula resulting from duodenal diverticula are presented. In both cases, the diverticula were located on the outer border of the second portion of the duodenum. The upper gastrointestinal study is the easiest and most useful examination for diagnosis. Hypotonic duodenography and the barium enema complement the upper series and serve to differentiate benign from malignant fistulas.

PULMONARY COMPLICATIONS OF GASTROESOPHAGEAL REFLUX/HIATAL HERNIA IN CHILDREN

As part of a retrospective analysis of gastroesophageal reflux (GER) and/or hiatal hernia (HH) in infants and children, all chest films obtained during the month prior to or following an upper gastrointestinal study on 507 consecutive children (April 73-June 75) were reviewed for pulmonary abnormalities (clinically manifest or unsuspected) consisting of either single or multiple areas of consolidation, emphysema, or both. GER and/or HH was found in 209 (41%) of the total group studied and in 55 (67%) of the 82 children with positive chest findings (P<0.001). The 55 pulmonary cases with GER and/or HH were significantly different in age distribution from the 27 patients without abnormalities of the cardia with 48/55 (87%) of the first group aged one year and under while only 14/27 (52%) of the second group fell into this age group (P<0.001). The clinical course and resolution of pulmonary abnormalities by x-ray were related to the presence or absence of cardioesophageal (CE) abnormalities in that either chronic, shifting, and/or recurrent changes were found in 9/27 (33%) of cases without and 26/55 (47%) of cases with GER and/or HH. Finally, in those cases with GER/HH, persistent pulmonary changes occured in 21/35 (60%) with major reflux (grades 3-5) but in only 5/20 (25%) with minor reflux (grades 1 - 2, delayed only) and hiatal hernia only (P<0.02). Tufts Medical School (New England Medical Center Hospital) Department of Pediatrics, Boston.

The incidence of hiatal hernia in infants and children. Results of a survey of members of the Society for Pediatric Radiology.

A questionaire regarding the incidence of hiatal hernia in infacts and children was sent to the 50 largest departments of pediatric radiology in the United States and Canada. The 36 returned revealed that the larger departments see an average of 3.2 hiatal hernias per year or about 0.62 per cent of their upper gastrointestinal studies.

Radiologic diagnosis of pancreatic cancer

Modern radiology makes possible an accurate diagnosis of pancreatic cancer in about 95 percent of cases. Conventional upper gastrointestinal study, isotopic scanning, hypotonic duodenography, and ultrasonography are suitable as screening procedures. Special methods of high accuracy - pancreatic arteriography, endoscopic pancreatography, and transhepatic cholangiography are used as needed for definitive diagnosis.

Gastric leiomyosarcoma: roentgenologic and clinical findings.

The roentgenologic and clinical findings are reviewed in 11 patients with gastric leiomyosarcoma. The tumors were predominantly exogastric lesions in the proximal one-half of the stomach, producing extrinsic pressure on the stomach and smooth stretching of overlying gastric mucosa. Ulceration or cavitation in the tumor was present in 5 instances, with fistula leading into an exogastric cavity in 3. In 2 cases retained barium was noted in an exogastric cavity 24 hr after upper gastrointestinal study. Gastric leiomyosarcoma should be considered in the differential diagnosis of any exogastric soft tissue mass. Extraluminal gas lucencies within the mass lend further support to the diagnosis, and an exogastric tumor with ulceration or cavitation in the tumor will most often be leiomyosarcoma of the stomach. Evidence of gastrointestinal hemorrhage, upper abdominal pain, fever, or a palpable abdominal mass are helpful clinical points for correlation in diagnosis.

Upper gastrointestinal studies with acid and alkaline barium sulfate suspensions.

Many studies have been reported indicating that the contents of the stomach and small intestine influence the appearance of administered barium sulfate suspensions (1, 5, 9). This depends on the type of barium suspension used: plain barium sulfate versus preparations containing suspending agents. Frazer et al. (9) demonstrated that in normal subjects hypertonic solutions and long-chain and certain short-chain fatty acids cause a segmentation pattern in the small bowel apparently secondary to increased mucin secretion stimulated by these substances. Chang and Carroll (6) described marked mottling and flocculation of barium in the stomach in patients with hyperacidity and a frothy, foamy, and bubbly appearance in those with hypoacidity. Bryk and Robinson (4) showed that, in pyloric obstruction due to duodenal ulcer, hypersecretion and hyperacidity lead to precipitation and layering of barium while in neoplastic obstruction with its associated hypoacidity precipitation and layering are less common. Knoefel et al. (13) performed in vitro studies which indicated that the precipitation of barium was related to the volume and acidity of the gastric juice and its mucoprotein content. In the small bowel abnormal patterns have been described with duodenal ulcer (2), the Zollinger-Ellison syndrome (7, 15, 22), the malabsorption syndrome (5, 19), and a large number of other conditions which alter the bowel contents (2). These studies have indicated that the abnormalities noted are most prominent with plain barium sulfate suspensions and are completely or almost completely eliminated with the use of barium suspensions containing suspending agents. In duodenal ulcer and in the Zollinger-Ellison syndrome, it was postulated that the abnormalities were due to the large volume and the low pH of the gastric contents presented to the small bowel. A study in dogs (17) showed that instillation of 0.1 N HCl into the stomach increased the fluid volume of the ileum, increased its free acid content, and produced diarrhea. Multiple studies have been reported on the effect of administered acid or alkali on gastric emptying. These have generally agreed that in most normal adults acid solutions delay gastric emptying while isotonic solutions of alkali hasten emptying (11, 12, 18, 21). No studies, however, have been done on the roentgenographic gastric, duodenal, and small bowel patterns resulting from the use of barium sulfate suspensions whose pH has been adjusted to the equivalent of either the gastric or the duodenal contents. Acid barium (pH 1.7) has been recently described (8) as useful in evaluating clinical esophagitis, but its effect on the remainder of the gastrointestinal tract has not been described. No studies on the roentgenographic patterns produced by alkaline barium suspensions are available.

Temporary Impairment of Vitamin B12 Absorption

WIDESPREAD use of gastric freezing rapidly followed its introduction for the treatment of peptic ulcer. Despite this current vogue therapeutic results have been variable and temporary, and several hazards are known to be associated with the technique, We have demonstrated another untoward side effect which was previously thought not to occur. 1 Method Twelve male and four female patients, 24 to 67 years of age, with nonobstructing peptic ulceration of the duodenum documented by an upper gastro-intestinal study received a single, 60-minute period of gastric freezing employing a gastric hypothermia machine, as described by Peter and co-workers. 2 Inflow temperatures of —15 to —19 C (5 to —2.2 F) and outflow temperatures of —11 to —14 C (12.2 to 6.8 F) were maintained with a constant flow rate of 500 cc per minute. The volume of the standard, latex rubber balloon was the maximal consistent with patient comfort and ranged

A One-Year Experience with a Remote-Control Closed-Circuit Television System in a Private Office

One year's experience with a remote-control x-ray and closed-circuit television unit has offered us an opportunity to evaluate the newer image intensifier in the routine office practice of radiology. Our impressions regarding its value are offered in an individual and critical appraisal of the television viewing, photofluorography, and cine studies performed in over 1,000 upper gastrointestinal studies and approximately 500 colon examinations. Technic of Photofluorography and Cine Studies The examination of the stomach has been modified so that mucosal relief films could be obtained on 8 × 10-in. spot-films. After several swallows of barium, 1 radiograph is made in the upright position, 1 in the supine position, and then 2 oblique roentgenograms are taken, allowing the ingested air to fill the antrum and cap as well as the fundus and cardia. The patient then assumes the prone position for a roentgenogram which includes the antrum and duodenum. In this projection, the antrum is ironed out by the spine pressure. In the right oblique position, one or two divided 8 × 10-in. films are obtained to outline the duodenum and antral area of the stomach. Thus, 5 full 8 × 10-in. films and one or two divided 8 × 10-in. films with two exposures of the antrum and cap comprise the radiographic study. Cinefluorography subsequently records the fluoroscopic examination on 16-mm. films. To study the cardio-esophageal region, specifically for hiatus hernia, the patient is examined in the prone oblique position with a pressure sponge placed under the upper abdomen. While barium is being ingested through a straw, an automatically timed thirty-second exposure is made with 15 frames∕second speed set on the synchronized camera. The esophagus and cardia are filmed on the first run, and then another thirty-second exposure of the stomach including the duodenal loop is recorded. The colon examination is performed with some slight modifications. The patient lies on his left side and the barium flow in the lateral position is observed from the anus to the turn in the rectum or rectosigmoid area. At this point a 10 × 12-in. film is phototimed for recording. The patient is then placed on his back by the technician who stands at the foot end of the table while controlling the barium flow. Via an automatic pressure device, the sigmoid is uncoiled and high kilovoltage (130 kvp) 8 × 10-in. films are obtained in this region as well as about all the flexures. Finally, an 8 × 10-in. spot-film is made of the cecum and terminal ileum when the latter could be filled. Cine studies of the colon were performed only when disease was demonstrated or if a strip of film was desired for teaching purposes.

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL. CASE 6-1964.

Presentation of Case* A seventy-six-year-old man entered the hospital because of pain in the abdomen and diarrhea. The patient had been well until six months previously, when he experienced the first of numerous attacks characterized by the sudden development of pallor and a shaking chill followed by the frequent passage of watery brown stools for several days. The episodes occurred fortnightly for five months and then increased in frequency to about once a week. A barium-enema examination and an upper gastrointestinal study, performed at another hospital, were negative except for a few colonic diverticula; a small-bowel study showed abrupt narrowing . . .

The use of water-soluble urographic contrast media in paediatric gastrointestinal studies.

A clinical trial is reported of the use of water-soluble organic iodine compounds as gastrointestinal contrast media in the examination of infants and children. These preparations are non-toxic and are presumed less likely than barium to be harmful when aspirated. They provide good visualisation of the gross organ contours in routine upper gastrointestinal studies but barium sulphate appears superior in problems involving localised mucosal irregularities. A relatively high incidence of blood-stream absorption and visualised urinary excretion was noted, but no instance of systemic reaction to the medium has been observed to date.