Dennis M. Balfe

Swallowing dysfunction after cardiac operations: Associated adverse outcomes and risk factors including intraoperative transesophageal echocardiography

The frequency, importance to patient outcomes, and independent predictors of postoperative swallowing dysfunction documented by barium cineradiography were examined in 869 patients undergoing cardiac operations over a 12-month period. Swallowing dysfunction was diagnosed in 34 patients (4% incidence) and was associated with documented pulmonary aspiration in 90% of these patients, increased frequency of pneumonia (p < 0.0001), need for tracheostomy (p = 0.0002), length of stay in the intensive care unit (p = 0.0001), and duration of hospitalization after the operation (p = 0.0001). Independent predictors of postoperative swallowing dysfunction determined by multivariate logistic regression included age (p < 0.001), length of tracheal intubation after the operation (p = 0.001), and intraoperative use of transesophageal echocardiography (p = 0.003). Dysfunctional swallowing after cardiac operations, a serious complication significantly related to postoperative respiratory morbidity and extended length of hospitalization, is more common in older patients. An association between intraoperative use of transesophageal echocardiography and swallowing dysfunction was also observed in our patients.

FDG-PET evaluation of indeterminate pancreatic masses

PURPOSE The purpose of this study was to assess the ability of PET with 2-[18F]fluoro-2-deoxy-D-glucose (FDG) to differentiate benign from malignant pancreatic masses in patients with indeterminate findings on CT. METHOD We performed FDG-PET on 12 patients with indeterminate mass lesions and 2 patients with CT findings typical for malignancy. Eight were found to have pancreatic carcinoma and six had benign lesions. The final diagnosis was histopathologically confirmed in all patients but two with a presumed diagnosis of focal pancreatitis based on stable clinical follow-up for at least 12 months. Lesion uptake of FDG was evaluated qualitatively and semiquantitatively by determination of the standardized uptake value (SUV) RESULTS: With use of a 2.5 cutoff value for SUV, all eight malignant and four of six benign lesions were correctly categorized. Qualitative evaluation gave the same results. The two false-positive lesions had elevated SUV values of 3.4 and 3.8, respectively. CONCLUSION Our results indicate that FDG-PET has potential value for assessing patients with CT findings that are indeterminate for pancreatic carcinoma. FDG-PET may obviate invasive diagnostic procedures in many patients with benign disease.

Gastrointestinal Manifestations of Multiple Endocrine Neoplasia Type 2

ObjectiveTo determine the clinical features, natural history, and role of surgery for gastrointestinal manifestations of the multiple endocrine neoplasia type 2 (MEN 2) syndromes. Summary Background DataThe MEN 2 syndromes are characterized by medullary thyroid carcinoma and other endocrinopathies. In addition, some patients with MEN 2A develop Hirschsprung’s disease (HD), and all patients with MEN 2B have intestinal neuromas and megacolon that can cause significant gastrointestinal problems. MethodsFrom 83 families with MEN 2A, eight patients with HD were identified (MEN 2A-HD). These and all patients with MEN 2B followed at the authors’ institution (n = 53) were sent questionnaires to describe the onset and type of gastrointestinal symptoms and treatment they had before the diagnosis of MEN 2. Records of all patients responding were reviewed, including radiographic imaging, histology, surgical records, and genetic testing. ResultsThirty-six of the 61 patients (59%) responded (MEN 2A = 8, MEN 2B = 28) to the questionnaires. All patients with MEN 2A-HD were operated on for HD 2 to 63 years before being diagnosed with MEN 2. All patients responding were underweight as infants and had symptoms of abdominal pain, distention, and constipation. Eighty-eight percent had hematochezia, 63% had emesis, and 33% had intermittent diarrhea before surgery. All patients with MEN 2A-HD had rectal biopsies with a diverting colostomy as the initial surgical procedure. This was followed by a colostomy takedown and pull-through procedure at a later interval. Ninety-three percent of patients with MEN 2B had gastrointestinal symptoms 1 to 24 years before the diagnosis of MEN 2. Symptoms included flatulence (86%), abdominal distention or being underweight as a child (64%), abdominal pain (54%), constipation or diarrhea (43%), difficulty swallowing (39%), and vomiting (14%). Seventy-one percent of patients with MEN-2B with gastrointestinal symptoms had radiographic imaging, 32% were admitted to the hospital, and 29% underwent surgery. ConclusionsPatients with MEN 2A-HD had a typical HD presentation and always required surgery. Patients with MEN 2B have significant gastrointestinal symptoms, but less than a third had surgical intervention. Understanding the clinical course and differences in these patients will improve clinical management.

Aortoenteric Fistulas: CT Features and Potential Mimics

Prompt diagnosis of aortoenteric fistulas is imperative for patient survival. The clinical signs of aortoenteric fistula include hematemesis, melena, sepsis, and abdominal pain, but the condition also may be clinically occult. Because clinical signs may not be present or may not be sufficiently specific, imaging is most often necessary to achieve an accurate diagnosis. Although no single imaging modality demonstrates the condition with sufficient sensitivity and specificity, computed tomography (CT), owing to its widespread availability and high efficiency, has become the imaging modality of choice for evaluations in the emergency setting. CT has widely variable sensitivity (40%-90%) and specificity (33%-100%) for the diagnosis of aortoenteric fistulas. To use this modality effectively for the initial diagnostic examination, radiologists must be familiar with the spectrum of CT appearances. Mimics of aortoenteric fistulas include retroperitoneal fibrosis, infected aortic aneurysm, infectious aortitis, and perigraft infection without fistulization. Differentiation is aided by the observation of ectopic gas, loss of the normal fat plane, extravasation of aortic contrast material into the enteric lumen, or leakage of enteric contrast material into the paraprosthetic space; these features are highly suggestive of aortoenteric fistula in a patient with bleeding in the gastrointestinal tract.

Spiral computed tomographic colonography: Determination of the central axis and digital unraveling of the colon

RATIONALE AND OBJECTIVES The authors developed and tested automated and semiautomated bowel-lumen tracking and colon-unraveling techniques for determining the central axis of the bowel. METHODS A computer-simulated gastrointestinal tract phantom was used to test the accuracy of an automated algorithm for central axis determination and bowel unraveling. Variations in cross-sectional features between straight and unraveled formats were compared in a canine bowel segment in vitro and a human colon in vivo by using spiral computed tomography. Three readers each performed three semiautomated evaluations. RESULTS Accuracy of the automated algorithm was confirmed by the high degree of correlation in the cross-sectional feature measurements (length error, < 1%). For the canine colon segment, accuracy of the semiautomated algorithm was confirmed by comparison with the automated tracing. For the human colon, readings were reproducible with 3.3% (+/- 1.9 standard deviation) mean variation in length. CONCLUSION An automated algorithm for central axis deterioration and unraveling the colon has been validated in a gastrointestinal tract phantom. A semiautomated algorithm has been shown to be reproducible and time-efficient.

Computed tomography in malignant endometrial neoplasms

Malignant uterine neoplasms are the most common invasive gynecological malignancies. The prognosis depends on the history, the grade, and the stage. Recent reports have stressed that a small percentage of patients with clinically low stage disease have unsuspected metastases. We retrospectively reviewed 61 patients with known malignant uterine neoplasms. In 18 patients with preoperative computed tomographic examinations, these scans detected unsuspected omental metastases in two and pelvic adenopathy in three. There was one false positive and one false negative examination. Computed tomography was superior to the clinical examination in defining the extent of the tumor in five patients. Computed tomography was also helpful in evaluating patients with suspected recurrent disease.

Acute fat deposition in bowel wall submucosa: CT appearance.

Objective The deposition of submucosal fat in small and large bowel is known to occur in chronic processes such as inflammatory bowel disease, and has been assumed to reflect long disease duration. However, we have observed that submucosal fat deposition can occur in a short period of time. Materials and Methods Four patients were evaluated in whom serial CT examinations showed intramural fat deposition occurring within six months of a normal study. Confirmation of fatty deposition was made by Hounsfield unit measurement in all patients and by pathologic examination of bowel specimens in two patients. Results All four patients received cytoreductive chemotherapy for treatment of lymphoma or leukemia prior to the development of fat deposition. In all patients, serial CT examination documented the occurrence of fat-attenuation bowel wall thickening that developed in a short time period (12, 36, 67, and 186 days). Three of the four cases were initially misinterpreted as wall thickening from other causes (intussusception or colitis). Pathologic examination of bowel in the two patients with the shortest time intervals confirmed the presence of mature fat confined to the submucosa. Conclusion These cases demonstrate that submucosal fat deposition in bowel wall is not limited to inflammatory bowel disease and other longstanding, chronic diseases; fatty infiltration can occur in a relatively short period of time, and is particularly likely to occur after cytoreductive therapy.

Computed tomography of fatal hepatic rupture due to peliosis hepatis

Hepatic rupture with subcapsular hematoma and hemoperitoneum is shown by CT in a patient with peliosis hepatis. Peliosis hepatis is pathologically characterized by blood-filled cystic spaces in the liver associated with the administration of anabolic androgenic steroids or oral contraceptive agents, particularly those with large components of estrogen. We report a fatal case in a patient receiving diethylstilbestrol for 3 years. In patients receiving these medications, peliosis hepatis should be considered in the differential diagnosis of low attenuation areas in the liver by CT. These patients are subject to increased risk of spontaneous hepatic rupture.

Lymphoma in the wall of the bile ducts: radiologic imaging.

Extranodal lymphoma is not uncommon; however, lymphomatous involvement of the wall of the bile duct is rare, with only a few case reports available. Three cases were imaged with computed tomography (CT) and direct cholangiography at our institution. In one, Hodgkin disease recurred in the duct wall, producing a radiographic pattern indistinguishable from sclerosing cholangitis. In another, central sclerosis on cholangiography was associated with a separate liver mass identified by CT. This presentation of non-Hodgkin lymphoma mimicked cholangiocarcinoma. The third patient had multifocal, diffuse histiocytic lymphoma arising in the gallbladder and cystic duct, as well as in the kidneys and pancreas. Although the condition is unusual, the diagnosis of lymphoma in the bile duct wall should be considered, particularly when the cholangiographic picture of diffuse central sclerosis is associated with little or no observable mass on CT.

Computed tomography of portal vein thrombosis: Unusual appearances and pitfalls in diagnosis

In a review of 25 cases examined by CT in whom the diagnosis of visceral vein thrombosis had been made, we encountered four cases in which problematic CT findings led to an error in diagnosis by the prospective interpreter. In one case, gas in collateral periportal veins mimicked an abscess; in one case, segmentally occluded portal veins resembled dilated bile ducts; and in one case, expansion of the inferior mesenteric vein was interpreted as a pancreatic pseudocyst. One additional case of multiple intrahepatic stones mimicked calcified portal vein thrombus. Although most cases are straightforward, there is a spectrum of findings in visceral vein thrombosis that may lead to confusion; alternative imaging techniques may be necessary in these situations.