Yu Men Chen

Predictive relationship of hiatal hernia to reflux esophagitis

The relationship between hiatal hernia and reflux esophagitis was compared in 93 patients who underwent both radiographic and endoscopic examination of the esophagus. In 46 patients with a normal esophagus shown endoscopically, hiatal hernia was present in 59%, while 94% of 47 patients with reflux esophagitis had hiatal hernia. The positive and negative predictive values for hiatal hernia in diagnosing or excluding esophagitis were 62% and 86%, respectively. Extrapolation of these data and review of the literature suggest that much of the confusion concerning the relationship between hiatal hernia and reflux esophagitis is based on reports of populations with considerable variation in the prevalence of esophagitis and in which the radiographie criteria for diagnosing hiatal hernia have not been uniformly applied.

Multiphasic examination of the esophagogastric region for strictures, rings, and hiatal hernia: evaluation of the individual techniques

Three hundred multiphasic examinations of the lower esophagus and esophagogastric region were assessed to determine the individual sensitivities of the full-column, mucosal relief, and double contrast techniques in the detection of common structural abnormalities, such as hiatal hernia, lower esophageal rings, and peptic strictures. In 159 patients, there were 211 structural abnormalities including 153 hiatal hernias, 35 mucosal rings, 20 peptic strictures, and 3 esophageal diverticula. The overall sensitivity of the full-column technique in detecting these abnormalities was 100% compared to 52% and 34% for the mucosal relief and double-contrast techniques, respectively. We conclude that the prone full-column technique must be incorporated into any examination of the esophagogastric region if these common abnormalities are to be demonstrated reliably.

Radiographic evaluation of esophagus immediately after pneumatic dilatation for achalasia.

Forty-one (98%) of 42 patients with achalasia of the esophagus had pneumatic dilatation performed successfully using the Brown-McHardy dilator. One to four dilatations (mean, 1.9) were done on each patient with inflation pressures of 8–15 psi (mean, 11.1 psi). Immediately after the procedure, all patients were examined radiographically by injection of contrast material into the lower esophagus through a nasoesophageal tube. Two immediate and two delayed perforations occurred. Six intramural hematomas were noted, five of which resolved spontaneously. The luminal diameter at the esophagogastric junction increased from a mean of 4.2 mm before dilatation to 7.5 mm following treatment. Four patients with previous Heller myotomy were dilated without complications. Perforation was more common in patients with a minimal change in the esophagogastric diameter. Thirty-five patients (85%) improved symptomatically within several days following pneumatic dilatation. Excluding patients with perforation, the postdilatation appearance of the lower esophagus poorly correlated with clinical response.

Cowden's disease: A case report and literature review

Cowdens disease, or multiple hamartoma syndrome, is an uncommon condition with characteristic mucocutaneous lesions associated with abnormalities of the breast, thyroid, and gastrointestinal tract. We describe a 51-year-old man with hyperplastic polyposis of the entire alimentary tract as the most prominent feature of this disease. We also present a review of 85 cases of this entity as reported in the English medical literature, and summarize the pertinent findings.

Endoscopic sensitivity in the detection of esophageal strictures.

Endoscopy was compared in 90 patients with a radiographic diagnosis of peptic esophageal stricture. Retrospectively, 78 strictures were classified as valid diagnoses giving a positive radiographic predictive value of 87%. Endoscopy diagnosed 74 (95%) of the 78 peptic strictures, detecting all 45 strictures under 10 mm in caliber, but failing to detect four (12%) of 33 broader strictures. Nine (75%) of the 12 radiographic false-positive errors involved misinterpretation of muscular or mucosal rings of the lower esophagus. We conclude that endoscopy and radiology are equally effective and complementary methods for evaluating patients with suspected peptic stricture.

Natural Progression of the Lower Esophageal Mucosal Ring

Among 390 patients with endoscopically verified lower esophageal mucosal ring (LEMR), 22 cases were identified with previous or subsequent radiologic examinations of the esophagogastric region. Among these, it was found that 2 cases of LEMR had developed from a normal esophagus. In 3 patients, there was increasing stenosis of the LEMR. In 8 cases, the LEMR was transformed into an esophageal stricture. In 10 of the 13 cases, esophagitis of varying degree was present endoscopically. In the 9 patients exhibiting no change in the LEMR, only 1 patient had esophagitis. The data suggest that there is a potential progression from normal esophagus to lower esophageal ring to esophageal stricture that occurs in association with reflux esophagitis.

Analysis of a multiphasic radiographic examination for detecting reflux esophagitis

Radiographic and endoscopic findings were correlated in 46 normal patients and in 49 with reflux esophagitis to assess the efficacy of a multiphasic examination employing mucosal relief, full-column, and double-contrast techniques. Esophagitis was graded endoscopically as mild, moderate, or severe, and the quality and sensitivity of each technique and of the examination as a whole were determined. The radiographic specificity in the normal patients was 98%. The overall sensitivity was 65% for all grades of esophagitis, and 90% for the moderate and severe grades. Sensitivities of the individual techniques were: mucosal relief: 43%; full-column: 53%; double-contrast: 45%. These differences were not statistically significant. We conclude that a combination of radiographie techniques is needed to detect reflux esophagitis optimally.

Radiographic and manometric correlation in achalasia with apparent relaxation of the lower esophageal sphincter

We compared the clinical, radiographic, and manometric findings in 10 patients with atypical achalasia showing complete lower esophageal sphincter (LES) relaxation to 39 patients with classic achalasia (i.e., incomplete LES relaxation). Those with atypical achalasia were younger (46.1 vs 60.6 years), had dysphagia of shorter duration (18.7 vs 45.7 mos), had lost less weight (8.2 vs 21.5 lbs), and had less esophageal dilatation (2.8 vs 3.9 cm). However, the mean LES pressures (34.5 vs 37.7 mmHg) and the esophagogastric junction calibers (4.5 vs 4.8 mm) were similar. Radionuclide esophageal emptying studies were done in 15 patients (6 with atypical achalasia; 9 with classic achalasia) and were abnormal in all. Most patients in both groups (90 and 92%) responded well to pneumatic dilatation. We conclude that achalasia with apparent LES relaxation may represent an early form of this motor disorder and that the radiographic findings remain characteristic except for less dilatation of the esophagus.

Traumatic rectal hematoma following anal rape

We describe the case of a 28-year-old male prisoner with a traumatic rectal hematoma caused by anal rape. Barium enema showed a large rectal mass confirmed to be a hematoma by proctoscopic examination. Surgery was performed due to a falling hemoglobin level, and an 800-mL hematoma was evacuated. The patient became febrile following surgery, and computed tomography revealed a pelvic mass consistent with recurrent hematoma or abscess. Repeat surgery showed recurrent hematoma. The patient recovered uneventfully.

Radiology and Endoscopy: A Radiologic Viewpoint

Excerpt The article in this issue by Dooley and associates (1) again raises the question of the relative merits of endoscopy and radiology in the examination of patients suspected of having disease...