Charles Zwirewich

Twenty-year prevalence of diabetes mellitus and hypertension in patients receiving shock-wave lithotripsy for urolithiasis

Study Type – Prevalence (retrospective cohort)

Renal matrix calculus. Sonographic appearance.

The typical sonographic appearance of urinary calculi includes strong internal echoes and sharp posterior acoustic shadowing.1.2 Although acoustic shadowing may not be visible from stones measuring less than 2 mm in diameter, reports of larger nonshadowing calculi are rare. 3 The sonographic appearance of urinary matrix calculi has not been described. We present a patient with a partially calcified, yet nonshadowing, renal matrix calculus of 4.5 em in diameter.

Recurrent ectopic pancreatitis of the jejunum and mesentery over a 30-year period

BACKGROUND Ectopic pancreas is defined as pancreatic tissue found outside its usual anatomical position, with no ductal or vascular communication with the native pancreas. We describe a case of ectopic pancreas of the small bowel and mesentery causing recurrent episodes of pancreatitis, initially suspected on computed tomography (CT) and magnetic resonance cholangiopancreatography (MRCP), and confirmed on histological review of the resection. METHODS A 67-year-old woman presented with clinical symptoms and biochemical evidence of pancreatitis. She had similar episodes over the past 30 years with unrevealing investigations, and was concluded to have idiopathic pancreatitis. She underwent CT and MRCP, with findings suggestive of ectopic pancreas, a diagnosis confirmed on histology of the resection. RESULTS MRCP identified a mass in the proximal small bowel mesentery isointense to the native pancreas, with a small duct draining into a proximal jejunal loop. The resected specimen consisted of normal parenchyma with lobulated acinar tissue with scattered islets of Langerhans, an occasional ductular structure, and admixed areas of adipose tissue. The patient remained asymptomatic with normal biochemistry six months post-operatively. CONCLUSION In an individual with abdominal pain, elevated serum amylase/lipase, but imaging findings of a normal native pancreas, ectopic pancreatitis should be considered, and can be evaluated by CT and MRCP.

Translabial sonography of vaginal fibroids: report of 2 cases and review of the literature.

To determine the role of translabial sonography in the diagnosis of vaginal fibroids.

A Naturopathic Cause of Portal Venous Gas Embolism

Question: A 49-yearold man presented with severe epigastric pain and nonbloody emesis after ingestion of a naturopathic treatment for type 2 diabetes mellitus. He denied recent ingestion of nonsteroidal anti-inflammatory drugs and a prior history of chronic liver disease. In the emergency department, he was alert and orientated with a blood pressure of 140/84, a pulse rate of 80 beats per minute, and O2 saturation of 97% on room air. On hysical examination, he had moderate epigastric tenderness but without rebound, no abdominal distention, and normal bowel ounds. There were no localizing neurologic findings. Laboratory investigations revealed a white cell count of 11.4 giga/L, a emoglobin 153 g/L, and a lactate of 3.4 mmol/L. Urgent abdominal computed tomography was performed, which revealed extensive portal venous gas throughout the liver (Figure ) and pneumatosis with thickening of the stomach wall (Figure B). What is your diagnosis and treatment? Look on page 658 for the answer and see the GASTROENTEROLOGY web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.

MP38-06 ULTRA LOW DOSE CT-KUB TO DETECT KIDNEY STONES WITH 44% LESS RADIATION: IS THE PLAIN RADIOGRAPH OBSOLETE?

INTRODUCTION AND OBJECTIVES: At our institution, Kidney-Ureter-Bladder (KUB) radiographs are performed immediately prior to shockwave lithotripsy (SWL). Conventional low dose CT-KUBs (radiation effective dose of 2.2-3.0 mSv) are only performed if stones are not visible on KUB. Recent advances in CT detector design and image reconstruction algorithms have made sub-milliSievert ultra-low dose CT (ULDCT) acquisition feasible, but the diagnostic performance of these exams has not yet been reported. We sought to compare the radiation dose and diagnostic performance of ULDCT to KUB in patients prior to SWL. We hypothesized that ULDCT would provide at least the same amount of information as a KUB immediately prior to SWL. METHODS: Patients enrolled in this study consented and received both a KUB radiograph and an ULDCT prior to SWL. If no stones were identified, then a standard low dose abdominal CT was obtained. Radiation exposure parameters were recorded and both examinations were read in random order by blinded radiologists to determine the correlation between the two modalities. RESULTS: 51 patients (M:F, 34:17) with a mean age of 56.2 13.8y were enrolled. The effective radiation dose was significantly lower with ULDCT (0.28 0.10 mSv) compared to KUB (0.50 0.10 mSv, p1⁄40.014). The number of stones seen on both modalities was equivalent: KUB was 1.59 1.27 vs 1.92 01.51 for ULDCT (p1⁄40.35). Measurement of stone size was equivalent using ULDCT (6.47 3.34mm) compared to KUB (6.98 3.41mm, p1⁄40.455). In 3 cases (5.9%), the ULDCT helped localize ureteral stones that were not visible on KUB. ULDCT altered treatment priority of treating the ureteral stones first. CONCLUSIONS: Sub-milliSievert ULDCT delivers 44% less radiation than a plain KUB radiograph and was equivalent in detecting the number and size of stones. In 5.9% of cases, CT localized stones prior to SWL better than KUB. In future, ULDCT may replace KUB as it delivers less radiation with potentially more information immediately prior to SWL. Validation of this technology in the acute care setting in the Emergency Room will be necessary.