Water-soluble Contrast Medium Research Articles

Bologna guidelines for diagnosis and management of adhesive small bowel obstruction (ASBO): 2013 update of the evidence-based guidelines from the world society of emergency surgery ASBO working group

BackgroundIn 2013 Guidelines on diagnosis and management of ASBO have been revised and updated by the WSES Working Group on ASBO to develop current evidence-based algorithms and focus indications and safety of conservative treatment, timing of surgery and indications for laparoscopy.RecommendationsIn absence of signs of strangulation and history of persistent vomiting or combined CT-scan signs (free fluid, mesenteric edema, small-bowel feces sign, devascularization) patients with partial ASBO can be managed safely with NOM and tube decompression should be attempted. These patients are good candidates for Water-Soluble-Contrast-Medium (WSCM) with both diagnostic and therapeutic purposes. The radiologic appearance of WSCM in the colon within 24 hours from administration predicts resolution. WSCM maybe administered either orally or via NGT both immediately at admission or after failed conservative treatment for 48 hours. The use of WSCM is safe and reduces need for surgery, time to resolution and hospital stay.NOM, in absence of signs of strangulation or peritonitis, can be prolonged up to 72 hours. After 72 hours of NOM without resolution, surgery is recommended.Patients treated non-operatively have shorter hospital stay, but higher recurrence rate and shorter time to re-admission, although the risk of new surgically treated episodes of ASBO is unchanged. Risk factors for recurrences are age <40 years and matted adhesions. WSCM does not decrease recurrence rates or recurrences needing surgery.Open surgery is often used for strangulating ASBO as well as after failed conservative management. In selected patients and with appropriate skills, laparoscopic approach is advisable using open access technique. Access in left upper quadrant or left flank is the safest and only completely obstructing adhesions should be identified and lysed with cold scissors. Laparoscopic adhesiolysis should be attempted preferably if first episode of SBO and/or anticipated single band. A low threshold for open conversion should be maintained.Peritoneal adhesions should be prevented. Hyaluronic acid-carboxycellulose membrane and icodextrin decrease incidence of adhesions. Icodextrin may reduce the risk of re-obstruction. HA cannot reduce need of surgery.Adhesions quantification and scoring maybe useful for achieving standardized assessment of adhesions severity and for further research in diagnosis and treatment of ASBO.

Esophageal lung diagnosed following the primary repair of esophageal atresia with tracheo-esophageal fistula in a neonate

Communicating bronchopulmonary foregut malformations are a diverse group of congenital anomalies characterized by a fistula between the respiratory and alimentary systems. Among these malformations, the association of an esophageal lung with esophageal atresia (EA) and tracheo-esophageal fistula (TEF) is extremely rare. We report the case of a neonate with esophageal lung detected following the primary repair of EA with TEF. Despite the rarity of esophageal lung with EA and TEF, it should be considered to develop in infants with abnormal findings on chest radiographs and an unusual preoperative and/or in the postoperative clinical course of EA and TEF. Swallowing study with water-soluble contrast medium is the investigation of choice to demonstrate the anatomic connection, if EA and TEF were already primarily repaired. If not, although the use of preoperative CT may be debatable in neonates due to the associated radiation exposure, in selected cases such as our patient, preoperative CT can be useful for early preoperative diagnosis.

The utility of postmortem computed tomography selective coronary angiography in parallel with autopsy

Historically, coronary angiography of the isolated heart has played an important role in the detection of stenotic or occlusive lesions that are difficult to identify by autopsy alone. Meanwhile, although the application of multidetector computed tomography (MDCT) to forensic fields has accelerated recently, isolated single organ angiography with MDCT is rarely performed. In this article, we present an evaluation of postmortem selective coronary CT angiography of the isolated heart with MDCT and discuss its utility for autopsy. First, in a preliminary experiment using pig coronary artery, we examined the behavior of water soluble contrast material on postmortem computed tomography angiography (PMCTA) and found that better angiographic images were acquired when the viscosity of the contrast material was increased and CT was performed under conditions of sustained perfusion. Based on these results, we devised a selective coronary angiography procedure using a pressurized bag for drip infusion that can be performed easily, quickly, and at low cost. The angiographic images obtained provided useful supportive evidence of autopsy findings suggestive of ischemic heart disease. With active discussions underway in forensic fields on the proper use of postmortem computed tomography, PMCTA has also naturally attracted attention as it compensates for some of the shortcomings of CT alone. Although PMCTA typically involves whole-body angiography, if we view PMCTA as one of the many useful and supplementary tools available for autopsy, then isolated heart angiography continues to have utility in autopsy today.

Scirrhous colonic metastasis from lobular carcinoma of breast.

A 68-year-old woman presented complaining of 2months vague abdominal fullness and constipation. She had a history of surgery 5years ago for invasive lobular carcinoma of the left breast. She had good appetite without any severe symptoms such as vomiting, diarrhea, or hematochezia. No abnormal subcutaneous lymph nodes were detected, and blood tests showed no abnormalities including serum tumor markers. Whole-body computed tomography and bone scintigraphy revealed no tumor recurrences. However, endoscopic findings demonstrated a smooth stenotic lesion with submucosal thickening in the transverse colon, but the colonic mucous membrane was grossly normal. The 3-cm-long stenotic lesion was confirmed by colon imaging using water-soluble contrast medium. A biopsy specimen revealed diffuse infiltration of noncohesive malignant cells with round, atypical nuclei from lamina propria to subserosa. Taken together with immunohistochemistry, a diagnosis of metastatic lobular carcinoma from the breast was made, and transverse segmentectomy was done. Colonic metastasis of breast cancer should be included as a differential diagnosis of any abdominal symptoms, even though mild, when patients have a present or previous history of breast cancer.

Imaging of disorder of sex development

BACKGROUND AND OBJECTIVESDisorders of sex development (DSDs), formerly termed ambiguous genitalia, are a group of conditions where the external genitalia appear abnormal. It represents a true medical and social emergency that needs a multidisciplinary team approach for elucidation. The pediatric radiologist plays an important role in defining the genital anatomy that remains one of the most important factors in sex determination, in addition to chromosomal analysis.DESIGN AND SETTINGSA retrospective study, conducted between January 1995 and December 2010.MATERIALS AND METHODSImaging studies (ultrasound, genitogram, and/or magnetic resonance imaging) were performed in patients with ambiguous genitalia, confirmed by chromosomal analysis and appropriate hormonal investigations.RESULTSThe sensitivity of ultrasound is 89.5%, while its specificity reaches 100%. Retrograde genitogram is more invasive and less sensitive, as the yield of determining the presence of a uterus ± vagina is 84.2%. However, magnetic resonance imaging (MRI) is more sensitive for gonadal tissue identification. Its specificity reaches up to 100% and can provide detailed internal structures (uterus, fallopian tubes, and gonads).CONCLUSIONUltrasound examination is still the main modality of choice for screening patients with ambiguous genitalia. It is cheap and readily available everywhere. In addition to elucidating the uterus in 89.5%, it can also give more information on the adrenal glands. However, genitography is good—84.2% in elucidating genital anatomy—but it gives no information of the gonads and it is time consuming and invasive. MRI is helpful in cases with equivocal ultrasound, reaches 100% in elucidating internal extractor, and therefore could be reserved for that.

3:46 PM Abstract No. 47 - Imaging of the thoracic duct using C-arm CT lymphangiography (CTL) following ultrasound guided inguinal nodal injection in children with right to left shunts

Purpose To study the feasibility of C-arm CTL following ultrasound guided inguinal lymph node injection of water soluble contrast media in children with right to left shunts. Materials and Methods Patient 1 : A 4 year old boy with complex congenital heart disease developed recurrent right sided chylothorax which resolved followed by left chylothorax requiring several chest tubes. A lymphangiogram was performed to look for thoracic duct leak. Patient 2 : A 13 year old girl with multiple cutaneous epidermal nevi, simple renal and splenic cysts, multiple lytic bone lesions, bilateral interstitial lung disease, multiple left lower lobe pulmonary AVM’s developed recurrent chylopericardium. This was managed with pericardial drainage and lymphangiogram was performed to look for leak. Technique : Lipiodol could not be used due to the risk of systemic embolization in the presence of right to left shunts. Under ultrasound guidance bilateral inguinal nodes were accessed using 25G needles followed by slow hand injection of Optiray 320. 2D-fluoroscopic visualization of the pelvic and lumbar lymphatics up to L2 level was possible beyond which dilution of contrast from leakage across the wall of the lymphatics precluded visualization. C-arm CT (syngo Dyna CT®, Siemens Medical Solutions USA Inc.) of the chest was performed using 8s DR-body protocol and images were reconstructed. Results Patient 1 : C-arm CTL showed a lobulated pseudoaneurysm of the thoracic duct at the level of T6 adjacent to a surgical clip with normal course and caliber of the rest of the duct to its insertion into the left subclavian vein and no leak. Patient 2 : C-arm CTL showed reflux of contrast into dilated lymphatics in the mediastinum, left hilum and left lower lobe suggestive of lymphangiectasia with uninterrupted course of the rest of the duct to the left subclavian vein. No leak into the pericardium was seen but the study was limited by artifacts from pericardial drainage catheter and nasogastric tube. Conclusion C-arm CTL can successfully demonstrate thoracic duct anatomy and pathology in combination with ultrasound guided inguinal nodal injection of water soluble contrast agent in children with contraindication for oily contrast media.

Visualisation of the rectoanal inhibitory reflex with a modified contrast enema in children with suspected Hirschsprung disease

Patients with Hirschsprung disease lack the normal rectoanal inhibitory reflex, which can be studied with anorectal manometry or US. To see whether the rectoanal inhibitory reflex could be visualised with a modified contrast enema, thereby increasing the diagnostic accuracy of the contrast enema and reducing the number of rectal biopsies. Fifty-nine boys and 42 girls (median age, 12 months) with suspected Hirschsprung disease were examined with a modified contrast enema, supplemented with two injections of cold, water-soluble contrast medium, to induce the reflex. Two paediatric radiologists evaluated the anonymised examinations in consensus. The contrast enema findings were correlated with the results of rectal biopsy or clinical follow-up. Five boys and one girl (median age, 7.5 days) were diagnosed with Hirschsprung disease. The negative predictive value of the rectoanal inhibitory reflex was 100%. A contrast enema with signs of Hirschsprung disease in combination with an absent rectoanal inhibitory reflex had the specificity of 98% and sensitivity of 100% for Hirschsprung disease. The modified contrast enema improves the radiological diagnosis of Hirschsprung disease. By demonstrating the rectoanal inhibitory reflex in children without Hirschsprung disease, we can reduce the proportion of unnecessary rectal biopsies.

A Prospective Study on the Gastrografin Contrast Radiology in the Management of Small Bowel Obstruction

Objective: To investigate the value of the hyperosmolar water-soluble contrast medium Gastrografin® in choosing which patients with small-intestine obstruction, caused by post-operative adhesions, to treat conservatively. Summary Background Data: Post-operative abdominal adhesions represent the main aetiological factor for intestinal obstruction. The mortality rate from intestinal obstruction has been quoted at 5 – 10% . The most effective way to reduce the morbidity and mortality caused by post-operative adhesions is, therefore, through early diagnosis and appropriate treatment. Methods: A prospective Gastrografin® study was performed in patients with small-intestine obstruction from June 2010 to June 2011. Results: Fifty-eight patients with adhesive intestinal obstruction received Gastrografin® via a nasogastric tube. Direct abdominal radiographs were taken after 4 and 8 h. Thirty-nine patients (67.2%) had Gastrografin® in the right colon within 8 h and were considered to have partial obstruction. These patients commenced oral feeding even though abdominal radiographs revealed gas–fluid levels. In the remaining 19 patients (32.7%), Gastrografin® was not observed in the right colon within 8 h: five of the 19 patients (26.3%) were successfully treated conservatively; 14 of the 19 patients (73.7%) developed toxic signs and underwent surgery, with obstruction resulting from adhesive bands being confirmed at operation. Conclusions: Conservative treatment can be recommended for patients in whom contrast medium is observed in the right colon within 8 h following administration, regardless of the presence of obstruction signs. Absence of contrast medium in the right colon within 8 h cannot, however, be considered an indication for surgery.

Die Technik der Hepatikojejunostomie mit T-Drainage bei der Rekonstruktion schmalkalibriger Gallengänge nach Pankreaskopfresektion

After pancreatic head resection the reconstruction of small and fragile bile ducts is technically demanding, resulting in more postoperative bile leaks. One option for the reconstruction is the placement of a T-tube drainage at the site of the anastomosis. Standard reconstruction after pancreatic head resection was an end-to-side hepaticojejunostomy with PDS 5.0, 15-25 cm distally from the pancreaticojejunostomy. For patients with a small bile duct diameter (≤ 5 mm) or a fragile bile duct wall the reconstruction was performed with PDS 6.0 and a T-tube drainage at the side of the anastomosis. The reconstruction with a T-tube drainage at the site of the anastomosis is technically easy to perform and offers the opportunity for immediate visualisation of the anastomosis in the postoperative period by application of water soluble contrast medium. If a bile leak occurs, biliary deviation through the T-tube drainage can enable a conservative management without revisional laparotomy in selected patients. Whether or not a conservative management of postoperative bile leaks will lead to more bile duct strictures is a subject for further investigations. A T-tube drainage at the site of the anastomosis can probably not prevent postoperative bile leaks from a difficult hepaticojejunostomy, but in selected patients it offers the opportunity for a conservative management resulting in less re-operations. Therefore we recommend the augmentation of a difficult hepaticojejunostomy with a T-tube drainage.

Role of carbon dioxide angiography in management of below knee arterial lesions

IntroductionMany practitioners express concern about the adequacy of imaging using CO2 in the lower extremities, particularly in the distribution of the popliteal artery and below (5). Published results have varied considerably with respect to the validity of imaging this anatomy. ObjectivesReview our experience with CO2 angiography using CO2 angioset in evaluation and intervention of below knee arteries. Patients and methodsForty patients with lower limb ischemia were divided into two groups. The 1st group has normal kidney function, subjected to angiography with CO2 and water soluble contrast media (WSCM) as the reference standard (control). The 2nd group has subjected only to CO2 angiography due to one or more risk factors related to WSCM. CO2 angioset is a dedicated CO2 injection system used in all patients. In the 1st group; imaging findings on CO2 and WSCM angiography were compared while in the 2nd group; findings were compared with the post procedure clinical and color Doppler findings. ResultsAll arterial lesions detected on CO2 angiography were comparable to those obtained with WSCM in the control group. In the 2nd group; post procedure clinical and Doppler findings correlated well with angiographic findings and angioplasty results. CO2 angiography images have lower resolution compared to WSCM however, they were reliable for accurate diagnosis and to guide angioplasty. ConclusionCO2 angiography using CO2 angioset is considered a reliable alternate to WSCM in assessment of below knee arteries and provides a reliable roadmap to interventional procedures.

Severe adhesive small bowel obstruction

Adhesive small bowel obstruction is a frequent cause of hospital admission. Water soluble contrast studies may have diagnostic and therapeutic value and avoid challenging demanding surgical operations, but if bowel ischemia is suspected, prompt surgical intervention is mandatory. A 58-year-old patient was operated for extensive adhesive small bowel obstruction after having had two previous laparotomies for colorectal surgery, and had a complex clinical course with multiple operations and several complications. Different strategies of management have been adopted, including non-operative management with the use of hyperosmolar water soluble contrast medium, multiple surgical procedures, total parenteral nutrition (TPN) support, and finally use of antiadherences icodextrin solution. After 2 years follow-up the patient was doing well without presenting recurrent episodes of adhesive small bowel obstruction. For patients admitted several times for adhesive small bowel obstruction, the relative risk of recurring obstruction increases in relation to the number of prior episodes. Several strategies for non-operative conservative management of adhesive small bowel obstruction have already addressed diagnostic and therapeutic value of hyperosmolar water soluble contrast. According to the most recent evidence-based guidelines, open surgery is the preferred method for surgical treatment of strangulating adhesive small bowel obstruction as well as after failed conservative management. Research interest and clinical evidence are increasing in adhesions prevention. Hyaluronic acid-carboxycellulose membrane and icodextrin may reduce incidence of adhesions.

Radiation dose and image quality evaluation relative to different contrast media using cone-beam CT

Aims: To evaluate the radiation dose and image quality of an adult cone-beam CT (CBCT) with oil-based (OBC) and water-soluble contrast (WSC) material. Material & Methods: A total of 44 patients, range: 46–82 years, (male:female – 26:18) who underwent CBCT examination during transarterial chemoembolization. Each patient received two CBCT scans; energy used: 94.4 ± 4.75 kV (mean ± standard deviation), current: 424 ± 132 mA for WSC and 94.5 ± 4.7 kV, 423.5 ± 132 mA for OBC. The volume of WSC material injected was 12 ml and OBC was 4 ml. Result: WSC examination showed significantly (p < 0.05) decreased (5.83%) dose–area product compared with OBC. Hounsfield unit, noise, signal–noise ratio and contrast–noise ratio was higher for OBC (49.4, 19.44, 38 and 58%, respectively) compared with WSC (p < 0.05). Qualitative assessment of WSC data (median: 2, interquartile range: 1.5–2.5) showed higher image quality compared with OBC data (2.7, interquartile range: 2.3–3.9). Conclusion: A detectable reduction of radiation dose was achieved with WSC compared with OBC in CBCT imaging. Quantitative image-quality parameters reflect higher values for OBC compared with WSC in the liver parenchyma. Subjective analysis showed an exactly opposite result due to the streak artifacts from OBC material.

Prospective Evaluation of Oral Gastrografin® in the Management of Postoperative Adhesive Small Bowel Obstruction

Oral Gastrografin®, a hyperosmolar water-soluble contrast medium, may have a therapeutic effect in adhesive small bowel obstruction. However, findings are still conflicting, as some authors did not find a therapeutic advantage. So, this prospective, randomized, and clinical trial study was designed to determine the value of Gastrografin in adhesive small bowel obstruction. The primary end points were the evaluation of the operative rate reduction and shortening the hospital stay after the use of Gastrografin. A total of 84 patients were randomized into two groups: the control group received conventional treatment, whereas the study group received in addition of 100mL Gastrografin meal. Patients were followed up within 4days after admission, and clinical and radiological (if needed) improvements were evaluated. Although the results showed that Gastrografin can decrease the need for surgical management by 14.5%, no statistically significant differences were observed between the two groups (P = 0.07). Nevertheless, the length of hospital stay revealed a significant reduction from 4.67 ± 1.18days to 2.69 ± 1.02days (P = 0.00). The use of Gastrografin in adhesive small bowel obstruction is safe and reduces the length of hospital stay. As a result, the cost of hospital bed occupancy is reduced. Hence, if there was no indication of emergency surgery, administration of oral Gastrografin as a nonoperative treatment in adhesive small bowel obstruction is also recommended.

Early Encephalic Toxicity after Inadvertent Intrathecal Injection of Low Osmolar Contrast Medium

Only nonionic contrast media are allowed for intrathecal use because of their lower neurotoxicity. In case of inadvertent intrathecal administration of an ionic contrast medium, the typical following syndrome is called ascending tonic clonic seizure syndrome. We describe the case of a 61-year-old woman with low back pain who underwent myelography. Ioxaglate, a water-soluble ionic low osmolar contrast medium was accidentally injected intrathecally. She first presented encephalic signs of neurotoxicity, followed by opisthotonic spasms and respiratory distress. In our case, ioxaglate is a low osmolar agent, leading to early encephalic toxicity (preceding medullary signs), because of its cephalic migration. The patient was successfully treated by sedation, anticonvulsant therapy and fluid hydration. Intrathecal administration of an ionic contrast medium is clearly contraindicated. In case of inadvertent injection of a low osmolar product, encephalic signs are seen first.

Safe and Effective Treatment of Colorectal Anastomotic Stricture Using a Well-defined Balloon Dilation Protocol

PurposeTo present a well-defined protocol for balloon dilation for colorectal anastomotic strictures and evaluate clinical efficacy of the dilation in 42 patients. Materials and MethodsFrom October 1999 to June 2010, 42 patients (32 males and 10 females with mean age 52.1 years ± 16.3) with surgical colorectal anastomotic strictures who received transanal balloon dilation using a well-defined protocol were retrospectively investigated. After the procedure, a water-soluble contrast media study was performed to detect possible complications. Stricture diameter was measured 1 month after balloon dilation. Clinical outcomes and recurrence were evaluated with a median follow-up period of 63.7 months. ResultsThere were 47 dilation sessions performed in 42 patients. Technical success and clinical success were achieved in all patients. At long-term follow-up, 36 (85.7%) patients had complete improvement. No complications were observed in any patients. Stricture diameter 1 month after the procedure was 8.85 cm ± 3.23, which was a significant increase over stricture diameter before the procedure of 5.89 cm ± 2.64 (P < .001), showing increase in diameter by 50.3%. Four (9.5%) patients experienced symptomatic recurrence. Stricture diameter of the patients with recurrence was considerably larger than stricture diameter of other patients (P = .036). ConclusionsFluoroscopically guided balloon dilation using the protocol described is safe and clinically effective for treatment of colorectal anastomotic stricture.

The detection of cysto-biliary communications during surgery for liver hydatid cysts: let's speak the unspoken

We read with great interest the article by Kayaalp et al. (1), whose work identified biliary orifices using a bile test and described the use of suturing cysto-biliary communications to reduce postoperative biliary complications significantly following hydatid liver surgery. We would like to express our opinion that testing using the injection of normal saline into the biliary system has several disadvantages based on three important concerns. First, normal saline is colorless, and in some cases, small or hidden cysto-biliary communications may not be detected. Why did the authors not use a colored agent, such as methylene blue? Second, small daughter cysts and minor fragments of cysts in the biliary tree may not be detected by injecting normal saline. How did the authors evaluate the whole biliary tree in patients with cysto-biliary communications? Third, in some cases, especially for deep cysts with multiple connections, the whole cavity may not be observable by the naked eye using a colorless agent. How did the authors evaluate the cyst cavities in these patients? During routine surgical practice, we prefer injecting water-soluble contrast media and using cholangiography in patients with suspected cysto-biliary communications (Figure 1). If we detect leaks using cholangiography, we can inject methylene blue into the biliary system to find hidden orifices (2). There are certain advantages to using this technique. First, the surgeon can see the location and the diameter of the cysto-biliary communications and understand the severity of the problem. Second, using cholangiography, small daughter cysts or minor fragments of endocysts in the biliary tree can be detected. Third, hidden biliary-thoracic communications can be visualized. Fourth, the use of cholangiography may prevent the complete suture capture and occlusion of biliary branches when suturing cysto-biliary communications.

Pregnancy outcome after hystero-salpingo-contrast-sonography (HyCoSy) versus hysterosalpingography (HSG) using different contrast media

The main conventional imaging modalities used to assess female tubal patency are hysterosalpingography (HSG) and Hystero-salpingo-contrast-sonography (HyCoSy), which could also be used to guide tubal recanalization. It is a comparative study, which aims to test whether the use of a homogenously mixed saline and air contrast sonography could enhance the chance of spontaneous clinical pregnancy in women undergoing subfertility investigation, this is compared with other contrast media used for Hysterosalpigography (HSG). Couples with at least 1 year of infertility who were scheduled for a consultation including a hysterosalpingo-contrast-sonography (HyCoSy) were invited to participate in the study. We compared flushing with a homogenously mixed saline and air as a water-soluble contrast medium, compared with another group who used either Oil Soluble (OSCM) or Water Soluble (WSCO) as contrast media for HSG. Randomization sequence was computer generated, stratified for age and group allocation was concealed. Primary outcome was clinical pregnancy, defined as a sonographically visible fetal sac, detected within 6, and 12 months from randomization, after confirmation of tubal patency. Secondary outcomes were spontaneous miscarriage and birth. Exclusion criteria were female age > 40 years, severe male infertility, previously known severe tubal infertility and suspected anovulation. The mean age of the study population ( n = 334) was 31.9 years. Duration of infertility was 2.1 years. The clinical pregnancy rate was .31% in the HyCoSy group and 22% in the non-flushing group, compared with 33% after HSG, using oil soluble medium, and 32% after using soluble medium in HSG. Differences in reproductive outcome among contrast material groups were not statistically significant (x28 5 6.08, p. 5.64). Whatever the cause of infertility, the use of different contrast materials led to no significant differences in the rates of live births. The pregnancy rates after performing HyCoSy using the proposed homogenously mixed saline and water are nearly the same as those following HSG using different contrast media with inherent advantage of avoiding exposure to radiation.

Visualisation of the temporary cavity by computed tomography using contrast material

The temporary cavity of a missile produces radial tears in ordnance gelatine, which correlate to the energy transfer. Computed tomography is a useful and non-destructive method to examine gelatine blocks. However, the tears give only few radiocontrast by air filling, which decreases with the time past shooting. Therefore, systematically, a radiocontrast material was searched to enhance the contrast. Different contrast materials were amalgamated to acryl paint, and about 7 g was sealed in a foil bag, which was integrated in the front of a standard 10% gelatine cylinder. Shots with Action-5 expanding bullets were performed from a 5-m distance. Gelatine was scanned by multi-slice computed tomography. The multiplanar reconstructed images were compared to mechanically cut slices of 1 cm thickness. It was shown experimentally that iodine containing water-soluble contrast material did not give sufficient contrast and caused diffusion artefacts. Best results were obtained by barium sulphate emulsion. The amount of acryl paint was sufficient to colour the tears for optical scanning. The radiocontrast of barium leads to satisfying imaging of tears and allowed the creation of a three-dimensional reconstruction of the temporary cavity. Comparison of optical and radiological results showed an excellent correlation, but absolute measures in computed tomographic (CT) images remained lower compared with optically gathered values in the gelatine slices. Combination of paint and contrast material for CT examination will facilitate the evaluation of complex ballistic models and increase accuracy.

Case Scenario: Self-extraction of Intrathecal Pump Medication with a Concomitant Intrathecal Granulomatous Mass

Case Scenario: Self-extraction of Intrathecal Pump Medication with a Concomitant Intrathecal Granulomatous Mass

Bologna Guidelines for Diagnosis and Management of Adhesive Small Bowel Obstruction (ASBO): 2010 Evidence-Based Guidelines of the World Society of Emergency Surgery

BackgroundThere is no consensus on diagnosis and management of ASBO. Initial conservative management is usually safe, however proper timing for discontinuing non operative treatment is still controversial. Open surgery or laparoscopy are used without standardized indications.MethodsA panel of 13 international experts with interest and background in ASBO and peritoneal diseases, participated in a consensus conference during the 1st International Congress of the World Society of Emergency Surgery and 9th Peritoneum and Surgery Society meeting, in Bologna, July 1-3, 2010, for developing evidence-based recommendations for diagnosis and management of ASBO. Whenever was a lack of high-level evidence, the working group formulated guidelines by obtaining consensus.RecommendationsIn absence of signs of strangulation and history of persistent vomiting or combined CT scan signs (free fluid, mesenteric oedema, small bowel faeces sign, devascularized bowel) patients with partial ASBO can be managed safely with NOM and tube decompression (either with long or NG) should be attempted. These patients are good candidates for Water Soluble Contrast Medium (WSCM) with both diagnostic and therapeutic purposes. The appearance of water-soluble contrast in the colon on X-ray within 24 hours from administration predicts resolution. WSCM may be administered either orally or via NGT (50-150 ml) both immediately at admission or after an initial attempt of conservative treatment of 48 hours. The use of WSCM for ASBO is safe and reduces need for surgery, time to resolution and hospital stay.NOM, in absence of signs of strangulation or peritonitis, can be prolonged up to 72 hours. After 72 hours of NOM without resolution surgery is recommended.Patients treated non-operatively have shorter hospital stay, but higher recurrence rate and shorter time to re-admission, although the risk of new surgically treated episodes of ASBO is unchanged. Risk factors for recurrences are age <40 years and matted adhesions. WSCM does not affect recurrence rates or recurrences needing surgery when compared to traditional conservative treatment.Open surgery is the preferred method for surgical treatment of strangulating ASBO as well as after failed conservative management. In selected patients and with appropriate skills, laparoscopic approach can be attempted using open access technique. Access in the left upper quadrant should be safe. Laparoscopic adhesiolysis should be attempted preferably in case of first episode of SBO and/or anticipated single band. A low threshold for open conversion should be maintained.Peritoneal adhesions should be prevented. Hyaluronic acid-carboxycellulose membrane and icodextrin can reduce incidence of adhesions. Icodextrin may reduce the risk of re-obstruction. HA cannot reduce need of surgery.