Hans Herlinger

A modified technique for the double-contrast small bowel enema

A small bowel enema technique is described which makes it possible to achieve double-contrast images comparable to those routinely obtained in the stomach or colon. It is a biphasic procedure, requiring the transtubal injection of barium sulfate, followed by 0.5% methylcellulose. Adjustment of relative injection quantities and injection speeds can adapt each examination to a patients individual diagnostic problem. Indications for the examination are discussed.

Granular cell tumors of the esophagus

An unusual benign multicentric esophageal granular cell tumor (granular cell myoblastoma) associated with 16 other similar tumors in the skin, vulva, breast, and tongue of 1 patient is described. There was a family history of granular cell tumors in the patients mother; this has not been previously described. The pathologic findings and controversial histogenesis of granular cell tumors are discussed in an effort to delete the erroneous term “myoblastoma” from the radiologists vocabulary. Granular cell tumors of the esophagus are also specifically reviewed.

Radiologic management of small bowel obstruction: A practical approach

The value of diagnostic imaging in the assessment of small bowel obstruction lies in its ability to answer questions to improve the clinical management of patients. These questions include: Is the small bowel obstructed? What are the level, cause, and severity of obstruction? Is strangulation likely to be present? Should treatment be operative or nonoperative? In this article, the different methods of contrast examination of the small bowel are reviewed, and recommendations to facilitate selection and performance of barium studies for small bowel obstruction are given. The indications for enteroclysis and computed tomography are discussed. A practical plain film-based approach to the diagnosis and management of small bowel obstruction is presented. Radiology assumes considerable importance and responsibility since it is able to supply relevant answers to many of the questions concerning small bowel obstruction.

Annular malignancies of the small bowel

True annular malignancies of the small bowel with mucosal destruction and shelflike margins are generally thought to be caused by primary adenocarcinoma. At our institution, 18 annular malignancies were diagnosed radiographically in the small bowel by enteroclysis (16 cases) and conventional small bowel follow-through studies (2 cases) between 1977 and 1984. However, pathologic data revealed only 4 primary adenocarcinomas with 10 metastatic lesions (6 colon cancers, 2 malignant melanomas, 1 lung cancer, and 1 cervical cancer), 2 leiomyosarcomas, 1 non-Hodgkins lymphoma, and 1 malignant carcinoid tumor. While these lesions may be indistinguishable radiographically, annular carcinomas tended to be short, relatively nonobstructing lesions; annular metastases (except those from malignant melanoma) tended to be highly obstructing lesions with significant narrowing and/or angulation of the bowel. Leiomyosarcomas, lymphoma, and metastases from malignant melanoma tended to be longer lesions with extensive ulceration, wider channels, and little or no evidence of obstruction. Nevertheless, surgical resection or biopsy of the lesion is ultimately required for a definitive diagnosis.

Cytomegalovirus gastritis : protean radiologic features

Infection with cytomegalovirus (CMV) is a major feature of acquired immunodeficiency syndrome (AIDS). Gastrointestinal involvement is being seen more frequently. Our collective experience involves nine patients with stomach involvement. Seven patients were intravenous drug abusers or homosexuals with AIDS. One developed CMV gastritis as a complication of leukemia and one patient was a West African with lymphoma and human immunodeficiency virus (HIV) infection. All our patients had biopsy-proven CMV inclusion bodies. The radiographic appearances varied widely. The findings included markedly thickened edematous folds, erosive gastritis with aphthous ulceration, and superficial and deep ulceration. One patient had deep ulceration with fistula formation. Computed tomographic (CT) scans confirmed the greatly thickened gastric wall and coarsened folds in two patients. Associated gastrointestinal infections included candida and herpes, and, in addition, pneumocystis carinii pneumonia (PCP) was present in two patients. CMV gastritis may mimic several other conditions including erosive gastritis, peptic ulceration, lymphoma, and carcinoma. It should be strongly considered in immunosuppressed patients.

Isolated Gastric Varices: Splenic Vein Obstruction or Portal Hypertension?

The presence of isolated gastric varices without esophageal varices is thought to be highly suggestive of splenic vein obstruction. A review of our radiologic files revealed 14 patients with isolated gastric varices on barium studies performed during the past 10 years. Eight of the 14 patients had adequate clinical and/or radiologic follow-up to suggest the pathophysiology of the varices. Seven had evidence of portal hypertension, and the remaining patient had evidence of splenic vein obstruction. Six patients had signs of upper gastrointestinal (GI) bleeding. Double-contrast upper GI examinations revealed thickened, tortuous fundal folds in 6 patients and a lobulated fundal mass in 2. Thus, most patients with isolated gastric varices have portal hypertension rather than splenic vein obstruction as the underlying cause.

Spontaneous perforation of the small intestine due to scleroderma

SummaryWe have described a 42-year-old black woman with scleroderma who developed spontaneous perforation of the terminal ileum due to complete collagenous involvement of the bowel wall. Spontaneous intestinal perforation represents a rare complication of scleroderma which can be initially mistaken for pseudoobstruction.

PREOPERATIVE DIAGNOSIS BY ENTEROCLYSIS OF UNSUSPECTED CLOSED LOOP OBSTRUCTION IN MEDICALLY MANAGED PATIENTS

Initial observation and evaluation of patient progress have reduced the number of operative interventions in the management of small intestinal obstruction. The differentiation of simple mechanical from strangulating obstructions has remained difficult. Strangulation is not an invariable component of a closed loop obstruction. We report 27 patients with small bowel obstruction initially managed nonsurgically, in whom enteroclysis 2-8 days after admission demonstrated unsuspected closed loop obstruction. In 25 of the 27 patients, subsequent surgery confirmed the radiologic diagnosis: all the obstructed loops were viable and there was no operative mortality. Our experience suggests that the early performance of enteroclysis should be considered in patients with small bowel obstruction undergoing a trial of nonoperative management.

Mesenteric border linear ulcer in Crohn disease: historical, radiologic, and pathologic perspectives

Linear ulcers located along the mesenteric border of the small intestine are an important, virtually pathognomonic sign of Crohn disease. A long, thin, linear barium collection extends parallel to the mesenteric border of the distal small intestine, accentuated by a thin radiolucency comparable to an ulcer collar (Fig. 1). Sacculation or folding of relatively uninvolved small bowel is seen opposite the mesenteric border ulcer. Folds extend from the antimesenteric border toward the ulcer. Although mesenteric border ulcers change as Crohn disease progresses, they are still recognized in about 30% of all patients. Because mesenteric border ulcers are so characteristic of Crohn disease, they deserve to be designated as a ‘‘sign,’’ hence our use of ‘‘the mesenteric border linear ulcer sign of Crohn disease’’ (MBUS). This article will review the historical aspects, radiologic features, and pathologic basis of the mesenteric border ulcer sign of Crohn disease.

Thirteen primary adenocarcinomas of the ileum and appendix: a case report.

Adenocarcinomas of the ileum and appendix are uncommon. Multiple synchronous adenocarcinomas of the small bowel without carcinoid features are even more unusual, with only seven reported cases in the literature. The radiologic and pathologic findings are reported in a case with 13 separate, well‐documented synchronous primary adenocarcinomas of the ileum and appendix. The value of the doublecontrast small bowel enema is emphasized.