Robert E. Koehler

Diverticular Disease in Patients with Chronic Renal Failure Due to Polycystic Kidney Disease

Twelve patients with chronic renal failure and polycystic kidney disease represent 8% of the 151 hemodialysis patients followed up at the Chromalloy American Kidney Center, Washington University School of Medicine. Ten (83%) of these patients have diverticulosis, and four of these patients developed gross colonic perforation secondary to diverticulitis. Barium enemas on 31 chronic renal failure patients without polycystic kidney disease revealed diverticulosis in 10 (32%). None had diverticulitis. Barium enemas in 120 age-matched non-renal failure control patients revealed diverticulosis in 45 (38%). None had diverticulitis. These findings suggest that patients with chronic renal failure due to polycystic kidney disease have a high incidence of diverticulosis and diverticulitis, that diverticulosis occurs in patients with chronic renal failure without polycystic kidney disease at a rate similar to that in the general population, and that diverticulitis should be an initial consideration in the differential diagnosis of abdominal pain in patients with polycystic kidney disease.

Arteriographie Demonstration of Collateral Arterial Supply to the Liver after Hepatic Artery Ligation1

Eight patients were studied arteriographically after hepatic artery ligation (done to control bleeding in 6). Sources of arterial flow to the liver after ligation were (a) replaced or accessory hepatic artery; (b) interlobar collaterals in the liver; (c) right inferior phrenic artery; (d) through the gastroduodenal artery from arterial branches in the pancreas, duodenum, and omentum; (e) fine collateral branches of the gastroduodenal artery as they pass into the porta hepatis; and (f) recanalization of the ligated hepatic artery. Collateral vessels, seen as early as four hours after ligation, increased in size and number during the following six months.

Complementary use of ultrasound and computed tomography in studies of the pancreas and kidney.

113 cases of pancreatic and renal disease studied by both ultrasound and computed tomography (CT) were analyzed retrospectively. CT provided a diagnosis when pancreatic ultrasound was unsuccessful due to overlying bowel gas or obesity and when renal ultrasound was unsuccessful due to obesity, reverberations from ribs, small lesions, or multiple lesions. Conversely, ultrasound provided a diagnosis when CT was unsuccessful due to lack of fat planes or respiratory motion. CT usualy distinguished carcinoma from pancreatitis when ultrasound showed a focal echogenic mass. CT resolved renal cyst from neoplasm when ultrasound showed a mixed echo pattern mass.

Early radiographic manifestations of carcinoma of the esophagus.

The survival of patients with esophageal carcinoma is greatest if treatment is begun when the tumor is small and confined to the esophagus. To better define the early radiographic manifestations of this disease, we analyzed the clinical and pathological information and the radiographs from 9 patients with esophageal carcinomas 3.5 cm or less in diameter. All tumors involved one wall of the esophagus and most appeared as plaques or flat sessile polyps, occasionally with central ulceration. Air-contrast views of the distended esophagus demonstrated the tumors to best advantage and should facilitate early detection.

Abdominal tuberculosis: CT findings.

The computed tomographic (CT) characteristics of intraabdominal tuberculosis are not specific. A recent article from South Africa proposed a set of criteria that included high density ascites and mesenteric involvement, consisting of thickening and adenopathy, as possible criteria for the diagnosis of tuberculous peritonitis by CT. Review of three additional cases of abdominal tuberculosis showing these findings supports the criteria defined in the earlier study. Although not definitive, these findings in the appropriate clinical setting should suggest the possibility of tuberculosis.

Ultrasonic localization of a non-palpable testis tumor

A young man was found to have a retroperitoneal seminoma and normal testicles by palpation. Initial diagnosis was an extratesticular primary germ cell tumor until ultrasound examination detected a lesion in the left testicle. A left radical orchiectomy was done and a seminoma of the testicle was found. We recommend ultrasound examination of the testicles to demonstrate occult testicular tumors when faced with the possibility of an extratesticular primary germ cell tumor.

Cholecystosonography: Accuracy, Pitfalls and Unusual Findings

Gray scale cholecystosonograms in 200 patients were reviewed. The findings in 133 of the patients were proved correct at surgery or autopsy. The overall accuracy for the detection of gallstones was 92 percent, with a false-negative rate of 4 percent. A false-positive diagnosis of cholelithiasis was made in three patients, two of whom proved to have extensive cholesterolosis. Causes of false-negative studies were the presence of a single small calculus, obseity and a large distended gallbladder. Ultrasound was specific but insensitive in the detection of a thickened gallbladder wall. The significance of a nonvisualized gallbladder by ultrasound and the role of ultrasound in the diagnosis of gallbladder disease are discussed.

Assessment of patients with failed gastric operations for morbid obesity

The success of gastric restriction procedures for morbid obesity depends on a persistently small gastric pouch and stoma, an intact staple line, and, of equal importance, dietary compliance. Evaluation of patients with either excessive or inadequate weight loss should be directed at determining both the technical adequacy of the operation and the depth of understanding the patient has of his or her role in the success of the procedure. Because of the poor prognosis for weight loss, patients who are not likely to be complaint or who demonstrate a lack of understanding of the behavioral modification required to ensure the success of the procedure should not have reoperation, even if a large pouch or stoma or a disrupted staple line is seen on an upper gastrointestinal series.

Computed tomographic angiography of the body.

Large and medium-sized blood vessels can be identified on extracranial computed tomographic (CT) scans when a combination of infusion and bolus injection of conventional contrast material is administered. The cases illustrated in this report show that CT angiography can sometimes offer clinically useful information not present on CT scans obtained without contrast injection.

Nodular duodenitis. Pathologic and clinical characteristics in patients with end-stage renal disease.

This prospective study evaluated the radiographic, endoscopic, histologic, and clinical characteristics of nodular duodenitis found in 17 of 50 (34%) patients with end-stage renal disease. By comparison, nodular duodenitis was noted in only 23 of 557 (4%) consecutive endoscopies in a general medical population. Endoscopic nodular duodenitis consisted of two or more nodules, 2.5–7.0 mm in diameter, with apical erythema, with or without tip erosions. Eight patients had nodules in the bulb only, eight had diffuse duodenal nodules, and a single patient had nodules only in the second portion of the duodenum. Singlecontrast barium x-rays were sensitive in detecting the nodules only when they were 5 mm or greater in diameter. Some degree of inflammatory infiltrate was found in 14 of 17 (82%) of the patients with nodular duodenitis; 10 of 17 had a moderate to severe histologic grade compared to 3 of 18 (P=0.015) patients with a normal endoscopic appearance to the duodenum. Several patients with endoscopic nodular duodenitis, in whom biopsies were taken both of the nodule and surrounding mucosa, were found to have a focal histologic lesion which consisted of villous blunting and thickening due to fibrosis and a chronic inflammatory infiltrate or lymphoid aggregate in the stroma. A higher incidence of peptic ulcers occurred in the nodular duodenitis group (3 of 17) compared to the remainder of the group (0 of 33) during a mean follow-up of 38 months (P=0.03). Resolution of the nodules occurred in six patients following successful renal transplant (four patients) and following vagotomy and pyloroplasty (two patients). These findings would suggest that nodular duodenitis, in patients with end-stage renal disease, represents a subset of duodenitis with a characteristic radiographic, endoscopic, and histologic appearance.