Manuel L. Brown

Impaired Transit of Chyme in Chronic Intestinal Pseudoobstruction

Chronic intestinal pseudoobstruction is a clinical syndrome whose pathophysiology, objective diagnosis, and treatment are poorly understood. We investigated 8 patients with this syndrome in whom intestinal dysmotility was established manometrically by two or more of the following criteria: abnormal configuration or propagation of interdigestive motor complexes, sustained incoordinate pressure activity, non-propagated bursts of phasic pressure activity, and failure of a solid-liquid meal to induce a fed pattern. To establish the functional impairment and region of the gut primarily affected by the disease, we quantified radio-scintigraphically the gastrointestinal transit of the solid (131I-fiber) and liquid (99 mTc-DTPA) components of a meal. Our techniques allowed us to quantify separately gastric emptying and pylorus-to-cecum transit. Furthermore, we evaluated the effects of a new prokinetic agent, cisapride. Gastric emptying times in pseudoobstruction were not significantly delayed; however, transit times through the small bowel (t1/2) were markedly prolonged [solids, 235 +/- 43 min (mean +/- SEM) vs. 138 +/- 25 controls, p less than 0.05; liquids, 310 +/- 67 vs. 181 +/- 28 controls, p = 0.07]. Cisapride was effective in reducing the delayed intestinal transit time to within the normal range (delta solids = -115 +/- 25 min; delta liquids = -146 +/- 71 min; p less than 0.05 for both). These studies suggest that intestinal dysmotility in this group of patients with pseudoobstruction was associated with delayed small bowel transit of radiolabeled solid and liquid components of chyme. Cisapride can restore to normal the delayed transit, indicating that it may potentially correct the impaired propulsive activity in the small bowel of these patients.

Limitations of indium leukocyte imaging for the diagnosis of spine infections

The usefulness of indium-111 white blood cell (WBC) scintigraphy in the detection of spine sepsis was studied in 22 patients who had open or percutaneous biopsies for microbiologic diagnosis. The indium images In 18 patients with vertebral infection were falsely negative In 15 (83%) and truly positive in 3 (17%). All four patients with negative cultures and histology had true-negative scans. The indium-111 WBC imaging results yielded a sensitivity of 17%,a specificity of 100%, and an accuracy rate of 31%. Prior antibiotic therapy was correlated with a high incidence of false-negative scans and photondeficient indium-111 WBC uptake. The usefulness of indium-111 WBC scintigraphy for the diagnosis of vertebral infection may be limited to those patients who have not been treated with antibiotics previously.

Scintigraphic assessment of the anorectal angle in health and after ileal pouch-anal anastomosis

To determine whether the anorectal angle was preserved after ileal pouch-anal anastomosis, a simple, safe, low-radiation, real-time method of imaging the anorectum was developed. A cylindrical balloon was placed in the neorectum and anal canal and filled with a solution of 99mTc in water. A gamma camera then imaged the angulation of the balloon while the subject was at rest, during sphincteric squeeze, and during a Valsalva maneuver. Thirteen healthy volunteers and six patients were studied after ileal pouch-anal anastomosis. An angle was identified in all controls and patients. In the lateral decubitus position at rest, the mean anorectal angle in controls (102 ± 18° SD) and anopouch angle in patients (108 ± 19°) were similar (p = 0.3). Sitting straightened the angle in both groups (p < 0.03), whereas sphincteric squeeze and a Valsalva maneuver sharpened the angle in both the sitting and standing positions (p < 0.03). In the lateral decubitus position, however, the pouch group was less able to sharpen the angle than were the controls (p = 0.04). In controls, the anorectal junction descended during sitting and elevated during squeeze (p < 0.03), but this did not occur in the pouch group. In conclusion, maneuvers favoring or stressing continence (squeeze, Valsalva) sharpened the anorectal angle and elevated the pelvic floor, whereas a maneuver favoring defecation (sitting) straightened the angle and caused the pelvic floor to descend. After ileal-anal anastomosis, the angle and its movements (except those while lying) were similar to controls. Elevation of the pelvic floor during squeeze, however, was decreased, indicating a decreased mobility of the pelvic floor after operation.

Radiation Absorbed Dose to the Lens in Dacryoscintigraphy with 99mTcO4−1

Calculations of the radiation dose to the lens for 99mTcO4- in dacryoscintigraphy are developed in some detail. The results indicate that the absorbed dose to the germinal epithelium of the lens is 2.2 X 10(-5) to 1.4 X 10(-4) rad/microCi (5.9 x 10(-12) to 3.8 x 10(-11) Gy/Bq) 99mTcO4- under physiological conditions. With blockage of the lacrimal drainage apparatus, the dose to the lens could increase to 4 X 10(-3) rad/microCi (1 X 10(-9) Gy/Bq).

Radiography and Scintigraphy in Tumoral Calcinosis

A case of tumoral calcinosis with tumoral deposits about the knee is reported. Radiographs demonstrate juxta-articular calcific deposits about the right second and fifth distal interphalangeal joints and the left first distal tuft, both hips, both shoulders, first distal phalanx of the left foot and right knee. Radionuclide images clearly demonstrate all areas of tumoral calcinosis.

PARATHYROMATOSIS: A CAUSE FOR RECURRENT HYPERPARATHYROIDISM

OBJECTIVE To report a case of parathyromatosis as a cause for recurrent hyperparathyroidism. METHODS We present the case history, laboratory results, operative interventions, and pathologic findings in a 36-year-old woman. Relevant reports from the literature are reviewed. RESULTS Our patient, who had been undergoing long-term hemodialysis because of renal failure, presented with secondary hyperparathyroidism and progressive bone pain. After an uneventful subtotal parathyroidectomy (removal of 3-1/2 glands), her symptoms resolved in conjunction with normalization of parathyroid hormone levels. Subsequently, however, recurrent hyperparathyroidism and severe bone pain necessitated second and third neck explorations, during which parathyromatosis was discovered. A total thyroidectomy was performed because of the bilateral nature of the disease. Postoperatively, the patients bone pain resolved substantially, although her parathyroid hormone levels remained high. CONCLUSION Parathyromatosis is a rare cause of recurrent hyperparathyroidism after parathyroidectomy. It consists of hyperfunctioning parathyroid tissues scattered throughout the neck, due either to intraoperative tissue spillage and subsequent implantation or to hyperplasia of parathyroid rests from embryologic development. This is one of the few case reports of parathyromatosis and the first case report of a mixed form of the disease, consisting of features of both subcapsular parathyroid rests and extracapsular implantation.

Clinical Significance of 99mTechnetium Sulfur Colloid Accumulation in Renal Transplant Patients

The accumulation of 99mtechnetium sulfur colloid (99mTcSC) was evaluated in 47 studies performed on 19 renal transplant patients by comparing its transplant activity to its bone marrow accumulation. There was a diagnosis of rejection of 21 of 22 studies (96.5%) in which marked transplant accumulation was noted. In 11 studies of patients with a clinical diagnosis of post-transplant acute tubular necrosis (ATN), the transplant activity varied from none to moderate. Rejection developed in 5 of 6 studies with minimal to moderate accumulation. Normally functioning renal transplant patients, or those with ATN and no superimposed rejection, do not show evidence of 99mTcSC accumulation.

A simple model for anatomic bone scanning studies.

A simple anatomic model for studying the scintigraphic appearance of various skeletal structures is described. The technique makes use of the fact that technitium pyrophosphate uptake in bone occurs by chemisorption to the surface of crystals in the bone matrix. By soaking clean bones in solutions of technetium pyrophosphate they can be rendered radioactive and subsequently studied by various imaging techniques.