Sergi Quiroga

Abdominal Distention Results From Caudo-ventral Redistribution of Contents

BACKGROUND & AIMS Abdominal bloating is a frequent symptom in various categories of patients; however, its origin is unclear. Our aim was to establish the mechanisms of abdominal bloating. METHODS The study evaluated 56 patients whose predominant symptom was abdominal bloating. Of these, 47 (44 female and 3 male; aged 19-74 years) were diagnosed with functional intestinal disorder by Rome II criteria and 9 (7 female and 2 male; aged 18-64 years) were diagnosed with intestinal dysmotility by gastrointestinal manometry. Computed tomographic scans were obtained before (basal level) and during a severe bloating episode. Control scans were also obtained from 12 healthy subjects (11 female and 1 male; aged 19-62 years). Morpho-volumetric differences between basal and severe bloating scans were measured using an original computer analysis program. RESULTS During severe bloating, patients with dysmotility exhibited anterior wall protrusion (23 +/- 4 mm; P < .001 vs basal) associated with a marked increase in total abdominal volume (1.4 +/- 0.3 L; P = .002 vs basal) and with cephalic displacement of the diaphragm. By contrast, in patients with functional intestinal disorder, total abdominal volume barely increased (0.3 +/- 0.1 L; P < .001 vs dysmotility); in these patients, abdominal distention (14 +/- 2 mm anterior wall protrusion; P < .001 vs basal) was related to diaphragmatic descent (-12 +/- 3 mm; R = -0.62; P < .001). CONCLUSIONS Abdominal distention might be caused by an increase in intra-abdominal volume or abdomino-phrenic displacement and ventro-caudal redistribution of contents.

Small bowel obstruction secondary to bezoar: CT diagnosis

Abstract. Two cases of small bowel obstruction secondary to phytobezoar diagnosed by computed tomography (CT) and confirmed at surgery are presented. CT findings were dilated intestinal loops and an intraluminal mass with air bubbles retained in its interstices, resulting in a mottled appearance. We propose that definite diagnosis of small bowel bezoar can be made on the basis of these CT findings.

Gas Distribution Within the Human Gut: Effect of Meals

BACKGROUND AND AIMS: Patients frequently complain of gas symptoms precipitated by meals, but the effect of early digestion on intestinal gas content remains unknown. Our aim was to determine the influence of meals on intestinal gas volume and distribution.METHODS:First, we developed a CT image analysis program, based on independent software modules, to measure gas content within the gut. The system was validated in nine healthy subjects by taking helical abdominal CT scans before and after rectal infusion of known volumes of air (100–400 mL). In 15 healthy subjects, intestinal gas distribution was measured in fast and early postcibal CT scans. The postcibal scan was taken 99 ± 22 minutes after a 597 ± 57 kcal meal.RESULTS:The volume of gas infused per rectum was detected with an accuracy of 100.4 ± 3.0%. During fasting, intestinal gas volume was 94 ± 7 mL (excluding two extreme outliers). After the meal, gas content within the gut increased by 64.7% (up to 149 ± 21 mL, P < 0.01 vs fast) and the increment occurred in the colon (59 ± 9 mL precibal vs 121 ± 20 mL postcibal, P < 0.001), while other gut compartments remained unchanged.CONCLUSION:Ingestion of a meal activated gas metabolism and increased gas content within the gut. The increment occurred early, presumably prior to colonic fermentation of food substrates and was localized in the distal gut, suggesting that gas had a proximal origin and was propelled caudally.

Intestinal Gas and Bloating : Effect of Prokinetic Stimulation

BACKGROUND:It is unknown if abdominal bloating is attributable to excess abdominal gas or improved by a prokinetic agent.AIMS:To assess abdominal gas content in functional abdominal bloating and to ascertain the effect of a prokinetic agent on intestinal gas symptoms in these patients.METHODS:In 20 patients, intra-abdominal gas content and symptoms were quantified before and during treatment with pyridostigmine (30 mg/8 hp. o) in this randomized, placebo-controlled, double-blind study. Daily symptoms were quantified for 5 days before and 10 days during treatment, and abdominal gas volume was quantified by CT imaging before and at the fourth day of treatment. A CT scan was also obtained in 10 healthy subjects.RESULTS:Before treatment, the total volume of intestinal gas was similar in patients (112 ± 18 mL) and in healthy controls (116 ± 20 mL). The treatment-induced change in total and regional intestinal gas volume was not significantly different between pyridostigmine (−4 ± 18 mL; mean ± SEM) and placebo (0 ± 15 mL). However, pyridostigmine reduced the severity of bloating from 3.3 ± 0.3 to 2.6 ± 0.4 (P < 0.05), whereas placebo did not (3.2 ± 0.3 vs 3.0 ± 0.4), although the change did not reach statistical difference across groups.CONCLUSION:In patients complaining of functional bloating, the volume and distribution of intestinal gas, measured on nonselected days, is comparable to asymptomatic subjects. Prokinetic stimulation improves bloating sensation without detectable changes in gas content.

Pancreatic metastasis of renal cell carcinoma: multidetector CT findings

Pancreatic metastasis of renal cell carcinoma is more prevalent than the rates reported in the literature before the development of multidetector computed tomography (MDCT). These lesions are usually asymptomatic and used to be an incidental finding detected on radiological follow-up of these patients. If they are not associated with extrapancreatic involvement, they show an excellent response to surgical treatment. Thus, radiologists should be aware of the radiological characteristics of this condition to allow detection at an early stage. In this article we review the MDCT features of four cases of pancreatic metastasis of renal cell carcinoma to familiarize radiologists with this entity and the most suitable study method for its detection. The main imaging findings observed were hypervascular lesions in arterial phase of biphasic studies, hence the detection of these lesions is performed better during the early phase scanning.

Hemoperitoneum as a First Manifestation of Hepatocellular Carcinoma in Western Patients with Liver Cirrhosis

Hemoperitoneum is a well-known form of hepatocellular carcinoma presentation and represents a frequent complication in countries with a high incidence of hepatocellular carcinoma, but it is rarely seen in Western countries. Our aim was to report the results and describe the arteriographic and CT-scan characteristics in a series of seven consecutive patients. They were admitted to our hospital because of hemoperitoneum due to ruptured tumor as a first manifestation of hepatocellular carcinoma, and the rupture was effectively controlled by transcatheter arterial embolization. From April 1989 to April 1998, 440 consecutive patients were admitted to our liver unit with the diagnosis of hepatocellular carcinoma and liver cirrhosis. Fourteen patients (3%) presented with acute hemoperitoneum due to tumor rupture as a first manifestation of hepatocellular carcinoma. We here report our experience in the group of patients treated by transcatheter arterial embolization. Mean age was 67.1 ± 5 years (range, 61–73). All patients presented with sudden abdominal pain, abdominal distension, and four patients had symptoms of acute anemia. In all cases the ruptured tumor was subcapsular. The procedure was effective in the control of bleeding in all cases, without significant impairment in liver function or treatment-related deaths. In six of the seven patients, a self-limited postembolization syndrome was observed. Mean survival time was 273 ± 488.7 days (range: 15–1290). Three patients survived more than six months but at the time of evaluation, only one patient was alive. In conclusion, the present results confirm that transcatheter arterial embolization is an effective and well-tolerated treatment in the management of hemoperitoneum due to ruptured hepatocellular carcinoma in patients with liver cirrhosis.

Abdominothoracic Mechanisms of Functional Abdominal Distension and Correction by Biofeedback

BACKGROUND & AIMS In patients with functional gut disorders, abdominal distension has been associated with descent of the diaphragm and protrusion of the anterior abdominal wall. We investigated mechanisms of abdominal distension in these patients. METHODS We performed a prospective study of 45 patients (42 women, 24-71 years old) with functional intestinal disorders (27 with irritable bowel syndrome with constipation, 15 with functional bloating, and 3 with irritable bowel syndrome with alternating bowel habits) and discrete episodes of visible abdominal distension. Subjects were assessed by abdominothoracic computed tomography (n = 39) and electromyography (EMG) of the abdominothoracic wall (n = 32) during basal conditions (without abdominal distension) and during episodes of severe abdominal distension. Fifteen patients received a median of 2 sessions (range, 1-3 sessions) of EMG-guided, respiratory-targeted biofeedback treatment; 11 received 1 control session before treatment. RESULTS Episodes of abdominal distension were associated with diaphragm contraction (19% ± 3% increase in EMG score and 12 ± 2 mm descent; P < .001 vs basal values) and intercostal contraction (14% ± 3% increase in EMG scores and 6 ± 1 mm increase in thoracic antero-posterior diameter; P < .001 vs basal values). They were also associated with increases in lung volume (501 ± 93 mL; P < .001 vs basal value) and anterior abdominal wall protrusion (32 ± 3 mm increase in girth; P < .001 vs basal). Biofeedback treatment, but not control sessions, reduced the activity of the intercostal muscles (by 19% ± 2%) and the diaphragm (by 18% ± 4%), activated the internal oblique muscles (by 52% ± 13%), and reduced girth (by 25 ± 3 mm) (P ≤ .009 vs pretreatment for all). CONCLUSIONS In patients with functional gut disorders, abdominal distension is a behavioral response that involves activity of the abdominothoracic wall. This distension can be reduced with EMG-guided, respiratory-targeted biofeedback therapy.

Usefulness of magnetic resonance spectroscopy for diagnosis of hepatic encephalopathy in a patient with relapsing confusional syndrome.

Magnetic resonance spectroscopy allows the assessment of several metabolites in brain tissue. In patients with hepatic encephalopathy, this technique shows a rise in glutamine and a decrease in myoinositol in brain tissue. However, the role of magnetic resonance spectroscopy in the diagnosis of hepatic encephalopathy is not known. We report the case of a patient with a relapsing confusional syndrome who underwent magnetic resonance spectroscopy. Previously, hepatic encephalopathy was ruled out because of the negative results of a transjugular liver biopsy and normal hepatic venous pressure gradient. The results of magnetic resonance were characteristic of hepatic encephalopathy. Abdominal computed tomography demonstrated large portosystemic shunts associated with cirrhosis of the liver. This case shows that magnetic resonance spectroscopy is an useful technique for the diagnosis of hepatic encephalopathy in selected cases, such as those without clinical signs of cirrhosis and/or large portosystemic shunts.

Spontaneous aortocaval fistula: CT findings with pathologic correlation

We present a case of aortocaval fistula (ACF) secondary to spontaneous rupture of an atherosclerotic infrarenal aortic aneurysm into the inferior vena cava that was initially diagnosed with computed tomography (CT). This is believed to be the first report of this condition with CT demonstration of the exact site of fistula and CT—pathologic correlation. We retrospectively reviewed the CT findings of another two cases of ACF and the previous literature.

Duodenal schwannoma causing gastrointestinal bleeding: helical CT findings.

Abstract. Neurogenic tumors of the small intestine are extremely rare and represent an unusual cause of gastrointestinal hemorrhage. We present a case of schwannoma of the fourth portion of the duodenum demonstrated by helical computed tomography. Multiplanar reconstructions showed a hypervascular tumor arising from the inferior wall of the duodenum. The use of water as oral contrast agent instead of iodinated contrast permitted a better visualization of the intact mucosa and differentiated a hypervascular tumor from hypodense gastrointestinal content.