Biomedical subjects
Publications and source records attributed to J L Clements.
A case is reported of monilial bezoar involving the jejunum following total gastrectomy in a patient who was neither severely debilitated nor immunosuppressed. This condition should be differentiated from the more commonly occurring postgastrectomy phytobezoar.
Between 1971 and 1976, ninety-three patients with a clinical diagnosis of pseudocyst confirmed by ultrasonography were identified from a group of 923 patients admitted for pancreatic disease. Uncertainties in diagnosis and/or rapid progression of underlying pancreatitis led to urgent laparotomy and drainage in eleven of the ninety-three patients. Another twenty-eight patients underwent elective drainage of the pseudocyst. The remaining fifty-four constituted the study group and were followed with serial clinical and sonographic examinations until either spontaneous resolution occurred, complications developed, or the patients did not return. Complications arising during the period of observation in the untreated patients (rupture, abscess, jaundice, and hemorrhage) occurred more than twice as commonly as spontaneous resolution (41 per cent versus 20 per cent), and led directly to death in seven cases (14 per cent). No deaths occurred in the group of patients undergoing elective surgical drainage (p less than 0.05). The interval between presumed formation of the pseudocyst and the development of a complication averaged 13.5 +/- 6 weeks. Prolonged observation of pancreatic pseudocysts in the expectation of spontaneous resolution exposed the patient to an unwarranted risk, which, after seven weeks, greatly exceeded the mortality of elective surgery.
The entity of multiple pyloric channels may be congenital but the majority are acquired lesions representing fistulae secondary to peptic ulcer disease in the pyloroduodenal region. The fistula usually joins the lesser curvature of the stomach with the superior aspect of the duodenal bulb. The multichannelled pylorus produces a characteristic radiological appearance on barium mean examination with a double or split barium column in the region of the pylorus. Four cases are described and illustrated.
A group of 53 patients with the diagnosis of antral mucosal diaphragm is reported. In over 50% of the cases the diaphragm was considered an asymptomatic lesion. In addition, an autopsy study in 29 unselected cases is reported with demonstration of five antral mucosal diaphragms in different forms. On the basis of these findings, it is evident that the antral mucosal diaphragm in the adult is not an acquired lesion secondary to peptic ulcer disease, but may be congenital. In addition, techniques of radiologic evaluation of the diaphragm for significant narrowing of the central aperture using the compressed barium tablet, and for significant gastric outlet obstruction using the "barium burger" examination, are described.
Five cases of unusual esophageal diverticula associated with progressive systemic sclerosis (scleroderma) or collagen vascular disease are presented. These wide-mouthed saccular diverticula were infrequently seen in a group of PSS patients with the typical motility disturbance of esophageal involvement and are reminiscent of the diverticula of the colon involved by PSS.
Three cases of unusual corrugated mucosal pattern in the esophagus accompanying the typical motility disturbance of progressive systemic sclerosis (PSS) are reported. The changes were rarely seen in a group of patients with esophageal involvement by PSS.
Six cases of intestinal pneumatosis following the jejunoileal bypass procedure are reported. Although the radiographic pattern of the pneumatosis intestinalis suggested severe disease, such as bowel infarction or necrotizing enterocolitis, all cases followed a benign course.
Pneumatosis intestinalis is a usually benign condition which may affect any segment of the gastrointestinal tract from the stomach to rectum. Occasionally, however, it may be a grave prognostic sign. This article presents the spectrum of diagnostic radiographic features of the entity with emphasis on differentiation of the underlying etiologic factors. Representative examples of pneumatosis intestinalis complicating various gastrointestinal disorders are illustrated.
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Of 92 patients with moderately severe acute pancreatitis initially studied within three weeks of onset by ultrasonic tomography, 52 developed an acute fluid collection in the lesser sac. Documentation of the ultrasound prediction of pseudocyst was achieved by surgery or autopsy in 26 cases. Spontaneous resolution of the acute pseudocyst was demonstrated by serial ultrasonography and radiogrphy in another 10 patients. Exploration exposed 3 false positive predictions of pseudocyst. Eleven other patients with a cystic configuration either refused surgery or were lost to followup. Acute pseudocyst formation is a relatively common phenomenon in the early phases of moderately severe pancreatitis. While spontaneous resolution of acute pseudocysts is frequent, in approximately 50% of cases acute pseudocysts progress to chronic pseudocysts. A distinction between acute and chronic pseudocyst is necessary since specific surgical management depends upon the phase of pseudocyst development. Unless regional sepsis supervens, acute pseudocyts of less than three weeks' duration may be followed by serial ultrasonography in the hope of spontaneous resolution. When a pseudocyst has achieved chronic status, spontaneous resolution is rare. Persistent conservative management under these conditions invites the excessive mortality and morbidity of spontaneous rupture.
Six cases are reported in which spontaneous internal drainage between a pancreatic pseudocyst and the alimentary tract became established. In each instance the communication was demonstrated radiologically. The clinical circumstances and radiographic features of these cases are described, and the existing literature pertaining to this phenomenon is reviewed.
A total of 99 patients admitted with a diagnosis of acute pancreatitis were studied by abdominal A- and B-mode ultrasonography in an effort to detect pseudocyst formation. Positive ultrasonic scans were noted in 52 cases. In three patients with positive sonography, surgical exploration did not demonstrate pseudocysts, giving a false positive rate of 8.3%. Of the negative studies four were proven incorrect at surgery or autopsy , yielding a false negative rate of 8.5%. Approximately one-fifth with cystic lesions underwent spontaneous resolution. Three additional patients with pseudocysts had spontaneous cyst-enteric fistulization demonstrated by radiography. The sensitivity and accuracy of pancreatic ultrasound demonstrated by this study established ultrasonography as the procedure of choice in detecting pseudocyst formation in patients with acute pancreatitis.
Among the protean presentations of pancreatic pseudocyst, spontaneous transenteric perforation is being reported with increasing frequency. Review of the literature revealed 37 cases in which the diagnosis of transenteric perforation of a pseudocyst could be substantiated, 21 reported since 1960. Five additional cases are described, including the first case of pseudocystesophageal fistulization. Of the 26 recent cases, chronic alcoholism was associated with fistulization in 73 per cent (19/26), males outnumbered females 2:1, and the age at diagnosis ranged from 23-74. No predilection for any particular segment of intestine was apparent. All the patients had symptomatology suggestive of pancreatic disease. In addition, 54 per cent (14/26) had intestinal hemorrhage. In that group of patients with a palpable abdominal mass, the sudden disappearance of the mass as transenteric decompression occurred was pathognomonic. Defivitive diagnosis was best established by a combination of ultrasound and barium intestinal studies. The overall mortality rate was 27 per cent (7/26), all of the deaths occurring in those patients with hemorrhage complicating the pseudocystenteric fistula. Since spontaneous closure of the fistula may be expected, surgery should be reserved for those patients with incomplete spontaneous drainage or uncontrollable hemorrhage.
The membrana angularis and pyloric torus defects are two physiologic bulges which can simulate ulcerations along the lesser curvature of the stomach. The muscular anatomy of the stomach and the mechanism which produces these pseudo-ulcers are discussed. Both pseudoniches can be seen transiently in normal individuals but occasionally are such prominence as to become diagnostic pitfalls. The features and significance of each pseudo-ulcer are reviewed in an attempt to facilitate recognition on the upper gastrointestinal barium examination.
Traumatic diaphragmatic hernia often is not recognized after the initial injury. Early recognition of this entity is of utmost importance since obstruction, strangulation, hemorrhage, viscus perforation, pleural fistula and empyema may occur at any time following the diaphragmatic disruption. A high index of suspicion, history of previous thoracoabdominal trauma, physical examination of the chest and roentgenographic evidence should aid in early and definitive diagnosis. Right-sided herniation should be considered in the differential diagnosis of masses about the right lower lung or diaphragm. Bilateral ruptures may also be encountered. Operation should be performed as soon as the diagnosis is made. In general, transabdominal route should be used in acute ruptures while chronic herniation should be approached through the chest.