Stephen E. Rubesin

Radiologic diagnosis of gastrointestinal perforation

Perforations of the gastrointestinal tract have many causes. Holes in the wall of gastrointestinal organs can be created by blunt or penetrating trauma, iatrogenic injury, inflammatory conditions that penetrate the serosa or adventitia, extrinsic neoplasms that invade the gastrointestinal tract, or primary neoplasms that penetrate outside the wall of gastrointestinal organs. This article provides a radiologic approach for investigating the wide variety of gastrointestinal perforations. General principles about contrast agents and studies are reviewed, and then perforations in specific gastrointestinal organs are discussed.

IMAGING MODALITIES IN INFLAMMATORY BOWEL DISEASE

This article provides an in-depth review of the radiologic and endoscopic imaging techniques used in the evaluation and management of inflammatory bowel disease (IBD). The use of imaging studies to diagnose IBD and to differentiate ulcerative colitis from Crohns disease is discussed. The evaluation of suspected complications associated with IBD, including strictures and fistulous disease, as well as surveillance for colorectal cancer are also addressed.

Epiphrenic Diverticulum: Clinical and Radiographic Findings in 27 Patients

The purpose of our study was to reassess the clinical and radiographic findings in patients with epiphrenic diverticula. A search of our radiology files revealed 27 patients with epiphrenic diverticula within 10 cm of the gastroesophageal junction. Medical records and radiographic reports and images were reviewed to determine the clinical and radiographic findings. Twenty-three patients had a solitary epiphrenic diverticulum, three had two diverticula, and one had three diverticula. The diverticula arose from the right side of the distal esophagus in 19 patients and the left side in eight. The diverticula had a mean width of 4.4 cm and a mean height of 3.7 cm. Other findings included prolonged retention of barium in the diverticula in 19 patients, preferential filling in 11, retained debris in 5, regurgitation of barium or debris in 5, compression of the esophagus in 5, pseudodiverticula formation in 3, and ulceration in 1. We found a significant correlation between the width of the diverticulum and preferential filling with barium. Twelve patients had abnormal esophageal motility, with diffuse esophageal spasm in two. Seventeen patients had symptoms attributable to the diverticulum (dysphagia in 11 and/or reflux symptoms in 12). We also found a significant correlation between the size or preferential filling of the diverticulum and the presence of symptoms. Conversely, we found no correlation between esophageal dysmotility and the presence of symptoms. Our experience suggests that the development of symptoms in patients with epiphrenic diverticula is more likely to be related to the morphologic features of the diverticula than to underlying esophageal motility disorders.

Computed tomography vs barium studies in the acutely symptomatic patient with Crohn disease

Gastrointestinal contrast studies and CT performed on 43 patients with known Crohn disease with acute symptoms were retrospectively reviewed to assess the ability of each study to define the location and extent of disease. In 39 of 43 (91%) patients the contrast studies and CT agreed on the location of active disease. However, in 15 of 43 (35%) patients, contrast studies demonstrated additional areas of mucosal disease remote from the major area of activity that were not suggested by CT. In addition to demonstrating more extensive mucosal disease, contrast studies proved superior in demonstrating enteroenteric fistulae, sinus tracts, strictures, postsurgical anatomy, and relation of recurrence to anastomosis. Computed tomography proved superior in demonstrating mesenteric inflammation, abscesses, enterovesical and enterocutaneous fistulae, fistula to iliopsoas muscle and to sacrum. We conclude that in the patient with suspected abscess, enterovesical or enterocutaneous fistula, CT is the study of choice. In other clinical circumstances both CT and contrast studies should be performed since they are complementary.

The Small-Caliber Esophagus: Radiographic Sign of Idiopathic Eosinophilic Esophagitis

PURPOSE To evaluate a small-caliber esophagus at barium esophagography with idiopathic eosinophilic esophagitis (IEE) and determine if there is a useful threshold diameter for suggesting this diagnosis. MATERIALS AND METHODS The institutional review board approved this retrospective study and waived informed consent. This study was HIPAA compliant. A search of the radiology database (by using the search term small-caliber esophagus) revealed 10 patients with a small-caliber esophagus at barium esophagography who had IEE (defined as more than 20 eosinophils per high-power field in endoscopic biopsy specimens). Images were reviewed to characterize findings and determine the length of narrowing. Luminal diameters were measured at three levels for nine patients and nine control subjects, and mean diameter, range, and standard deviation were determined at each level. An analysis of variance test was performed to determine whether the difference between the range of mean thoracic esophageal diameters in patients with IEE versus that in control subjects was significant. RESULTS All 10 patients had long-segment but variable-length narrowing of the thoracic esophagus (mean length, 15.4 cm) with tapered margins. The mean diameter at the aortic arch, carina, and one vertebral body above the gastroesophageal junction was 13.9, 14.3, and 15.1 mm, respectively, for patients with small-caliber esophagus versus 20.2, 30.3, and 28.7 mm for control subjects. The mean overall diameter was 14.7 mm for patients with small-caliber esophagus versus 26.3 mm for control subjects. In the nine patients in whom the luminal diameter was measured, the mean thoracic esophageal diameter was 20 mm or less; all nine control subjects had a mean thoracic esophageal diameter greater than 20 mm. The difference in the range of mean thoracic esophageal diameters between these two groups was highly significant (P < .0001), so 20 mm was a useful threshold diameter for suggesting this diagnosis. CONCLUSION The small-caliber esophagus of IEE is characterized at barium esophagography by long-segment but variable-length narrowing of the thoracic esophagus, with a mean length of 15.4 cm, a diameter of 20 mm or less, smooth contours, and tapered margins.

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 AND ENDOSCOPIC DIAGNOSIS OF CROHN'S DISEASE

This article reviews the radiologic and endoscopic diagnosis of Crohns disease. Radiographic and endoscopic findings of Crohns disease are discussed; a practical approach to the selection of radiologic modalities is presented; and the role of endoscopy in diagnosis and treatment is explained.

Detection of reflux esophagitis on double-contrast esophagrams and endoscopy using the histologic findings as the gold standard

Abstract The purpose of our study was to determine the accuracy of double-contrast barium studies and endoscopy for detecting reflux esophagitis, using the endoscopic biopsy findings as the gold standard. A review of radiology, endoscopy, and pathology files showed 37 patients with reflux symptoms who underwent double-contrast barium studies and endoscopy with biopsy specimens from the esophagus. The radiographic images were reviewed in a blinded fashion and correlated with the endoscopic and histologic findings to determine the radiographic and endoscopic accuracies for detecting reflux esophagitis, using the endoscopic biopsy specimens as the gold standard. Double-contrast barium studies and endoscopy had low but comparable accuracies for detecting reflux esophagitis, with sensitivities of 35% and 39%, specificities of 79% and 71%, positive predictive values of 73% and 69%, and negative predictive values of 42% and 41%, respectively. When mucosa granularity was evaluated as an individual sign of esophagitis on double-contrast studies, this finding had a sensitivity of 35%, a specificity of 93%, a positive predictive value of 89%, and a negative predictive value of 46% for detecting reflux esophagitis. Our experience suggests that double-contrast barium studies and endoscopy have limited ability to detect reflux esophagitis, in particular mild esophagitis, when using the histologic findings as the gold standard. When radiographic abnormalities are detected, however, mucosal granularity is the single best sign of reflux esophagitis on double-contrast studies.

Gastroesophageal reflux: comparison of barium studies with 24-h pH monitoring

OBJECTIVE To determine the correlation between massive gastroesophageal reflux (GER) on barium studies and pathologic acid reflux on 24-h pH monitoring. METHODS A search of hospital records from January 1997 to January 2001 revealed 28 patients who underwent both barium studies and 24-h pH monitoring. The radiologic reports were reviewed to determine the presence and degree of GER. Patients with reflux to or above the thoracic inlet either spontaneously or with provocative maneuvers in the recumbent position were classified as having massive reflux, whereas the remaining patients with reflux below the thoracic inlet or no reflux comprised the control group. The pH monitoring reports were also reviewed to determine if pathologic acid reflux was present in the recumbent position. The findings on these studies were then compared to determine the frequency of pathologic acid reflux in the recumbent position on pH monitoring in patients with massive reflux on barium studies compared with the control group. RESULTS Massive GER was observed on barium studies in 11 (39%) of the 28 patients and reflux below the thoracic inlet or no reflux in the remaining 17 patients (61%) who comprised the control group. All 11 patients (100%) with massive reflux on barium studies had pathologic acid reflux on pH monitoring in the recumbent position compared with six (35%) of 17 patients in the control group (P = 0.0009). The pH in the distal esophagus on pH monitoring was less than 4.0 for 13.1% of the recumbent period for patients with massive GER on barium studies compared with 6.2% of the recumbent period for the control group (P = 0.0076). CONCLUSION Although 24-h pH monitoring remains the gold standard for the detection of GER, our experience suggests that patients with massive reflux on barium studies are so likely to have pathologic acid reflux in the recumbent position that these individuals can be further evaluated and treated for their gastroesophageal reflux disease (GERD) without need for pH monitoring.

Jejunal Diverticulosis: Findings on CT in 28 Patients

OBJECTIVE The purpose of our study was to better characterize the CT findings of jejunal diverticulosis by retrospectively reviewing abdominal CT scans of 28 patients with this condition on barium examinations. CONCLUSION Jejunal diverticula have characteristic findings on CT, appearing as discrete round or ovoid, contrast-, fluid-, or air-containing structures outside the expected lumen of the small bowel, with a smooth, barely discernible wall and no recognizable small-bowel folds. Not infrequently, these structures are seen to communicate directly with an adjoining small-bowel loop, a feature best recognized by scrolling the images. Our experience suggests that jejunal diverticulosis can often be recognized on the basis of the characteristic CT features of this condition.