Solomon Schwartz

Pathophysiologic effects of bowel distention on intestinal blood flow

Abstract 1.1. The effects of acute bowel distention on intestinal circulation were studied in dogs. 2.2. Intraluminal pressures at or above 30 mm. Hg produced a consistent immediate fall in intestinal blood flow. Higher pressures produced correspondingly greater diminutions in flow until an irreducible 20 to 35 per cent of flow remained. 3.3. As blood flow fell, there was an associated decrease in the arteriovenous oxygen difference indicating diminished oxygen extraction by the intestine. 4.4. Injection studies performed in situ with increasing intraluminal pressures showed filling of only the submucosal and serosal vessels with pressures at or above 60 to 90 mm. Hg. 5.5. Krypton 85 washout studies are compatible with a shift of blood flow away from the mucosa at intraluminal pressures above 60 mm. Hg. 6.6. These findings indicate that above an intraluminal pressure of 30 mm. Hg, blood is shunted through functional or anatomic arteriovenous communications depriving the bowel mucosa. 7.7. The roles of increased intraluminal pressure, intestinal ischemia, and hypoxia are discussed as accounting for the colitis seen proximal to colonic neoplasms.

Roentgenologic aspects of reversible vascular occlusion of the colon and its relationship to ulcerative colitis.

Reversible vascular occlusion of the colon is a roentgenologic and clinical entity. Clinical and experimental evidence indicate that its manifestions may subside without sequelae and unnecessary surgery may be avoided by prompt recognition. Vascular insults of the small and large bowel have received much attention in the recent literature (7, 9, 10, 12). It is our intention to demonstrate the roentgen features of reversible vascular occlusion of the colon and to suggest an anatomic explanation for these findings. Only one of the several cases we have seen, will be presented in detail because of the unique combination of clinical, radiologic, sigmoidoscopic, and anatomic proof it affords. The other cases have been reported elsewhere (4). Case Report A 75-year-old white male presented with a five-day history of passing small quantities of bright red blood per rectum. There were no other complaints. Physical examination was nonrevealing. Hemoglobin was 10.2 gm. on admission and remained stable. On sigmoidosc...

Ischemic origin of ulcerative colitis associated with potentially obstructing lesions of the colon.

Abstract Ulcerative colitis often occurs in association with carcinoma of the colon. Of our 90 patients with colonic ischemia, 10% had associated neoplasms. The clinical, radiological, and pathological manifestations of ischemia were identical to those described previously. Experimental work suggests that increased intraluminal pressure and straining are causative, and this theory was supported by the demonstration of a similar type of colitis in patients with potentially obstructing lesions other than cancer. It is essential that the ischemic nature of the lesion be recognized when planning resectional therapy of the primary lesion.

Portal venous gas following a barium enema in a patient with Crohn's colitis

Hepatic portal venous gas occurring during an air-contrast bariumenema examination in patients with inflammatory bowel disease is a benign finding. Patients with chronic ulcerative colitis have experienced some morbidity, while those with Crohns colitis have not. It may not be necessary to treat all of these patients with antibiotics, especially asymptomatic patients with Crohns colitis.

Roentgen Findings in Intestinal Ganglioneuromatosis

Intestinal ganglioneuromatosis, part of the mucosal neuroma syndrome, is often associated with medullary thyroid carcinoma and pheochromocytoma. Barium enema studies demonstrate a distinctive triad of (a) an abnormal haustral pattern in the filled colon, (b) thickened mucosal folds on postevacuation films, and (c) colonic diverticula. These radiographic findings suggest the diagnosis of intestinal ganglioneuromatosis and raise the possibility of associated thyroid and adrenal tumors.

Plain Film Findings in Intussusception

1. Plain radiographs of the abdomen of 41 patients with intussusception were interspersed with those of 128 controls. 2. Four radiologists attempted to make a diagnosis of intussusception based solely on the plain film findings which have been described in the literature. 3. With the exception of a soft tissue mass or bowel obstruction, the various signs of intussusception were found generally to be either vague or non-specific and subject to a high degree of personal interpretation. 4. Clinical suspicion of intussusception warrants barium study regardless of plain film findings.

LYMPHOSARCOMA AND PERIURETERAL FIBROSIS.

Numerous terms have been applied to the condition resulting from fibrotic tissue surrounding, compressing, and occasionally occluding one or both ureters (3, 11, 14, 16, 20, 22). While the process usually involves the mid or upper portions of the ureters, involvement of the lower ureters, retroperitoneal vessels, kidneys, bladder, lungs, and mediastinum has been reported (1, 3, 5, 6, 18, 19). Multiple nonneoplastic etiologies have been surmised (3, 4, 6–8, 10, 11, 13, 15, 17, 22). Reticulum-cell sarcoma and Hodgkins disease, however, have been implicated (9, 21). We wish to report 4 cases in which periureteric fibrosis was found in association with lymphosarcoma, 3 of which were without antecedent irradiation to the retroperi-toneum. Case I: In this 68-year-old white woman generalized adenopathy developed in 1960. Biopsy of a left axillary node disclosed lymphosarcoma (Fig. 1). Intravenous pyelography in November 1960 and again in January 1961 revealed bilateral hydronephrosis and proximal hydroureter (F...

Gastrojejunal mucosal prolapse.

Gastrojejunal mucosal prolapse following subtotal gastrectomy is radiographically demonstrable and may be productive of symptoms. Mucosal prolapse occurs at both orifices of the intact stomach. Gastroesophageal (5, 6, 22) and esophagogastric (27, 28) mucosal prolapses have been documented. Since Schmieden (29) first reported gastrobulbar mucosal prolapse in 1911, many papers (7, 10, 13, 17, 19, 20, 24, 30) have appeared on this subject. Duodenogastric mucosal prolapse was recently demonstrated (18). It is our purpose to present 9 cases which we feel are examples of gastrojejunal mucosal prolapse. Since proof as to causation of the radiologic appearance was lacking, this entity was created in a dog, providing a method of confirmation. Subsequently Case I furnished us with operative proof. Case I: A 59-year-old Negro male underwent a subtotal gastrectomy, Hofmeister type, May 8, 1958, for chronic ulcer and bleeding. Following surgery, he had frequent episodes of epigastric discomfort after eating. He was re...

Roentgen exploration of the afferent loop.

Clinical problems attributable to afferent loop abnormalities in postgastrectomy patients are varied and poorly understood. The surgeon recognizes acute and chronic forms of obstruction; the internist uses the nebulous terms “chronic biliary vomiting” and “afferent loop syndrome.” The value of roentgenologic investigation in these problems has been consistently minimized. A number of authors have claimed that x-ray studies provide little information (1, 2, 6). It is our purpose to emphasize the value of detailed roentgen examination and to present our findings in 37 cases, of which 34 were symptomatic and 18 surgically proved. While much attention is currently focused on anatomic abnormalities subsequent to surgery, many of our cases are directly ascribable to other factors. Analysis of our findings indicates the desirability of reassessing the radiologic approach to afferent loop abnormalities and of providing a classification that includes more than surgically created causes of obstruction. Many authors...

SOME ASPECTS OF VASCULAR DISEASE OF THE SMALL INTESTINE.

VASCULAR compromise of the intestine may produce a broad spectrum of pathologic change; corresponding roentgen patterns are not specific for a given disease but reflect the stage of compromise. These patterns have been the subject of a previous paper (30). Recognition of an increasing number of cases of noncatastrophic vascular involvement of the small bowel has focused attention on their importance. Our experience would indicate that such minor insults are far more frequent than superior mesenteric occlusion. Some clinical, pathologic, and experimental aspects of this problem are presented in this paper. Arterial or arteriolar insufficiency and venous obstruction, congestion, and resultant oxygen deprivation may vary in degree. Similarly, the segment of small bowel involved may vary in length. The end-result depends upon an interplay between these factors and the collateral blood supply. Of all the intestinal layers, the mucosa is most sensitive to ischemia; therefore the earliest and mildest changes res...