A comment on "Incidence and patient characteristics associated with silent aspiration in the acute care setting" (Dysphagia 14:1-7, 1999)
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Acute Disease↗
Biomedical subjects
M I Burrell
Publications and source records attributed to M I Burrell.
Fiberoptic endoscopic evaluation of dysphagia to identify silent aspiration.
The traditional bedside dysphagia evaluation has not been able to identify silent aspiration because the pharyngeal phase of swallowing could not be objectively assessed. To date, only videofluoroscopy has been used to detect silent aspiration. This investigation assessed the aspiration status of 400 consecutive, at risk subjects by fiberoptic endoscopic evaluation of swallowing (FEES). Our study demonstrated that 175 of 400 (44%) subjects were without aspiration, 115 of 400 (29%) exhibited aspiration with a cough reflex, and 110 of 400 (28%) aspirated silently. No significant differences were observed for age or gender and aspiration status. The FEES, done at bedside, avoids irradiation exposure, is repeatable as often as necessary, uses regular food, can be videotaped for review, and is a patient-friendly method of identifying silent aspiration.
Adolescent↗
Tracheotomy tube occlusion status and aspiration in early postsurgical head and neck cancer patients.
The purpose of the present study was to investigate tracheotomy tube occlusion status and prevalence of aspiration utilizing videofluoroscopy. A prospective study was done of 16 consecutive, early, postsurgical head and neck cancer patients with tracheotomy. Selection criteria included the ability to tolerate tracheotomy tube occlusion prior to and during the modified barium swallow procedure, oral and/or pharyngeal surgical resection, no history of neurological disease or stroke, and medical clearance to begin oral feeding. There was 100% agreement among the independent reviewers on ratings of the presence or absence of aspiration. It was found that occlusion status of the tracheotomy tube did not influence the prevalence of aspiration in the immediate postoperative period. No trends were observed when comparing bolus consistency, type of tracheotomy tube, or presence/absence of a nasogastric tube and the ratings of aspiration.
Adult↗
Detection of choledocholithiasis: comparison of unenhanced helical CT and endoscopic retrograde cholangiopancreatography.
PURPOSE: To compare unenhanced helical computed tomography (CT) and endoscopic retrograde cholangiopancreatography (ERCP) in the detection of common bile duct calculi. MATERIALS AND METHODS: Within 13 months, 51 patients (aged 18-94 years) with clinically suspected choledocholithiasis underwent unenhanced helical CT immediately before undergoing ERCP. CT scans were evaluated for the presence of bile duct stones, ampullary stones, the gallbladder and gallbladder stones, intrahepatic biliary dilatation, and the size of the bile duct at the porta hepatis and in the pancreatic head. ERCP images were evaluated for the presence of bile duct or ampullary stones, as well as for biliary dilatation. RESULTS: Unenhanced helical CT depicted common bile duct stones in 15 of 17 patients found to have stones at ERCP. Three patients had stones impacted at the ampulla, all of which were detected with CT. In addition, there was one false-positive finding at CT. CT had a sensitivity of 88%, a specificity of 97%, and an accuracy of 94% in the diagnosis of common bile duct stones. CONCLUSION: Unenhanced helical CT is useful for evaluating suspected choledocholithiasis.
Adolescent↗
Differentiation of achalasia from pseudoachalasia by computed tomography.
OBJECTIVES: The purpose of this study was to determine the computed tomography (CT) findings in idiopathic achalasia and in the pseudoachalasia of malignancy. METHODS: We identified 12 patients with the manometric diagnosis of achalasia who also had CT scans available for review: eight had idiopathic achalasia, and four had pseudoachalasia. As controls, we selected nine patients with endoscopically obvious esophageal cancer who also had CT scans. The CT scans were blindly reviewed to determine esophageal wall thickness, symmetry of the esophageal wall, presence of esophageal dilation or mass, and a radiological diagnosis. RESULTS: Six of the eight patients with achalasia had a dilated esophagus. Five had symmetric wall thickening >5 mm (range 7-10 mm) at the gastroesophageal junction. One patient with a 10-mm wall thickening was incorrectly diagnosed with a mass. All others were correctly diagnosed with achalasia. Three of the four patients with pseudoachalasia had esophageal dilation. Two had an obvious esophageal mass. The other two were given an indefinite diagnosis: one had asymmetric wall thickening (11 mm) at the gastroesophageal junction, and the other had symmetric thickening of 18 mm. Eight of the nine patients with obvious esophageal cancer had a mass on CT; the other patient had asymmetric wall thickening of 6 mm at the gastroesophageal junction and was given an indefinite diagnosis. CONCLUSIONS: Most achalasia patients have CT findings of esophageal dilation and mild, symmetric wall thickening. Therefore, symmetric esophageal wall thickening (<10 mm) should not dissuade one from the diagnosis of achalasia. Most pseudoachalasia patients have CT findings of esophageal dilation, more marked and/or asymmetric wall thickening, or mass. In this group, asymmetric or marked thickening (>10 mm) indicated pseudoachalasia. Therefore, CT can be helpful in differentiating between achalasia and the pseudoachalasia of malignancy.
Adenocarcinoma↗
Effect of occlusion of a tracheotomy tube on aspiration.
The purpose of the present study was to investigate the effect of occlusion of a tracheotomy tube on aspiration utilizing fluoroscopy. Twenty consecutive tracheotomized patients referred for a modified barium swallow were included. Selection criteria were ability to tolerate tracheotomy tube occlusion during the modified barium swallow procedure, no surgery of the upper aerodigestive tract except tracheotomy, and no history of oropharyngeal cancer or stroke. There was 100% agreement among 3 independent reviewers on ratings of the presence or absence of aspiration. It was found that the occlusion status of the tracheotomy tube did not influence the prevalence of aspiration. Nine of 10 (90%) subjects who exhibited aspiration were over 65 years of age (mean = 72 years 2 months). No trends were observed for bolus consistency, type of tracheotomy tube, or presence/absence of a nasogastric tube and ratings of aspiration.
Adolescent↗
Pseudotumor of the pancreas associated with retroperitoneal fibrosis: a dramatic response to corticosteroid therapy.
A 69-yr-old man with a past medical history of aortic aneurysm and retroperitoneal fibrosis presented with obstructive jaundice and radiographic features suggesting sclerosing cholangitis and malignancy of the head of the pancreas. A presumptive diagnosis of chronic periaortitis was made, and a dramatic response to corticosteroid therapy was subsequently observed. The clinical course of seven additional patients with pseudotumor of the pancreas associated with retroperitoneal fibrosis is also reviewed; three of those patients also responded favorably to corticosteroid treatment.
Aged↗
Vascular compression of the esophagus: a manometric and radiologic study.
This study was undertaken to determine the prevalence of vascular compression in manometric tracings and to determine whether these findings had any clinical significance. Vascular compression, defined as a localized area of elevated intraesophageal resting pressure > 4 mm Hg with superimposed cyclic pressure spikes with a frequency of 60-100/min, was noted in 55 of 241 consecutive tracings. The groups with and without vascular compression were similar with regard to mean age, sex, and prevalence of dysphagia. Radiographs were available for 29 of the 55 and showed compression in 18, but there was no relationship with the manometric findings, except for a trend towards finding a positive esophagogram with amplitudes > 16 mm Hg. Eleven tracings showed absent "relaxation" of this elevation of pressure in response to swallows, and five of six available esophagograms showed a corresponding area of compression. We conclude that manometric evidence of vascular compression is common and generally has no clear relationship with esophagographic findings or dysphagia. However, the combined findings of marked increases in pressure and absence of relaxation in response to swallows may indicate evidence for a vascular cause of dysphagia.
Deglutition Disorders↗
Instrumental esophageal perforation: chest film findings.
The aim of this study was to evaluate plain film findings of the chest in instrumental esophageal perforation. We hypothesized that such "clean" perforations, often detected early, would be associated with a low frequency of abnormal plain film findings. Fifteen patients with instrumental esophageal perforation were identified, and their records and radiographs were reviewed. Twelve (80%) of the patients had abnormalities suggestive of perforation. The most common (60%) abnormality seen was pneumomediastinum. The second most common (33%) finding was a density adjacent to the descending aorta in the left cardiophrenic angle, resulting in loss of contour of the descending aorta at the level of the left diaphragm. We concluded that plain films, even when taken shortly after instrumentation, provide useful information regarding the presence of esophageal perforation.
Adult↗
Acute jejunoileitis. A distinct entity?
A 44-year-old man with acute jejunoileitis of unknown etiology developed small bowel obstruction. Intermittent abdominal pain, bloody diarrhea, ascites, and leukocytosis were prominent features. All stool cultures were negative. On steroid treatment, symptoms and radiographic features completely resolved. We suggest, in agreement with an earlier report, that acute jejunoileitis may be regarded as a distinct clinical entity.
Adult↗
The biliary tract: imaging for the 1990s.
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Biliary Tract↗
Pancreatic pseudotumors associated with multifocal idiopathic fibrosclerosis.
Two patients with multifocal idiopathic fibrosclerosis and sclerosing cholangitis developed biliary obstruction due to a fibrotic pancreatic pseudotumor. The masslike fibrosis mimicked pancreatic carcinoma on sonography and cholangio-pancreatography. In one patient sonography was successfully used to assess the response of the pseudotumor to corticosteroid therapy.
Cholangitis↗
Of cholescintigraphy, sonography, and great bears. A view on modern biliary imaging.
We review the discrepancies and the reasons for them, in two articles in this issue of the Journal to conclude that clinical findings hold the key to selection of the proper imaging test in biliary obstruction. Cholescintigraphy is a more rewarding approach in detecting low grade obstruction, as by common duct stones, whereas in the patient with prolonged painless jaundice, and the high likelihood of a malignancy, computed tomography or ultrasound will yield the best results. Because of the potential for noninvasive imaging to miss choledocholithiasis and because of ever increasing therapeutic options, direct cholangiography will continue to be the mainstay in definition evaluation of the biliary tract.
Cholestasis↗
Gallbladder perforation. An imaging analysis.
We evaluated the radiologic studies of 23 patients with surgically or autopsy-documented gallbladder perforation. Extravasation was shown by cholescintigraphy and cholangiography in seven patients and corresponded to free perforation or large pericholecystic loculation. In 16 patients, ultrasonography and computed tomography detected fluid and abscesses outside the gallbladder ranging from 1 to 2 mm pericholecystic fluid collections to large phlegmonous masses. A right, upper-quadrant mass on plain films and scattered calcification in this area suggested perforation. Gallbladder perforation could be diagnosed or suspected preoperatively in ten patients and antemortem in 22 of 23 individuals. This rate of recognition, higher than previously reported, may be ascribed in part to improvements in biliary imaging.
Adult↗
Intraluminal meniscoid ulcer in the colon: an unusual sign of malignancy.
An unusual sign of malignancy in the colon is described, consisting of an intraluminal lenticular ulcer surrounded by a meniscoid lucency of tumor. This constellation of findings was first described by Carman as a specific indicator of gastric malignancy. An aggressive ulcerating lesion with these characteristics, while rare in the colon, raises the suspicion of carcinoma.
Adenocarcinoma↗
Sclerosing cholangitis from intraarterial floxuridine.
The development of biliary strictures simulating sclerosing cholangitis is now well-known. We report a patient undergoing intraarterial chemotherapy for metastatic colon cancer of the liver in whom segmental intrahepatic biliary strictures occurred remote from known metastases. The patient remains alive 3-4 years after documented liver metastases with severe progressive portal hypertension, hypersplenism, and fat malabsorption. A table of cases so far reported is given.
Adenocarcinoma↗
CT demonstration of gastrointestinal involvement in Henoch-Schonlein syndrome.
The CT appearance of gastrointestinal involvement in Henoch-Schonlein syndrome is described. The protean manifestations of this disorder are easily confused both clinically and radiographically with those of many other conditions. Mural thickening, thickened folds, ulceration, and spasm are seen radiographically. The CT appearance of segmental mural thickening and luminal narrowing correlates well with the abnormalities seen on the small-bowel series and upper endoscopy.
Duodenal Diseases↗
Postcholecystectomy syndrome: evaluation using biliary scintigraphy and endoscopic retrograde cholangiopancreatography.
We prospectively studied 30 patients with postcholecystectomy syndrome to determine the efficacy of biliary scintigraphy in the detection of stenosis of the sphincter of Oddi. All patients underwent endoscopic retrograde cholangiopancreatography (ERCP). Biliary scintigraphy disclosed stenosis of the sphincter by agreement with the ERCP or surgical findings in nine (90%) of ten patients and in eight (100%) of eight patients with biliary obstruction from other causes. Retention of activity at 2 hours in visually prominent ducts was the best predictor of abnormal biliary drainage. Biliary scintigraphy is a useful, noninvasive screening test for the detection of postcholecystectomy biliary obstruction.
Adult↗