Biomedical subjects
Publications and source records attributed to S E Rubesin.
Swallowing requires the coordinated action of the alimentary tract from the oral cavity to the gastroesophageal junction. Any structural or functional abnormality along this pathway will interfere with swallowing. The "barium swallow" or pharyngoesophagogram requires examination of the oral cavity, pharynx, esophagus, and gastric cardia.
We present three patients with retroperitoneal tumor involving the duodenum in whom upper gastrointestinal (GI) studies revealed delayed gastric emptying and massive gastric dilatation out of proportion to the degree of duodenal dilatation. While the radiographic findings mimicked acute gastric outlet obstruction, delayed films demonstrated narrowing and encasement of the duodenum at the site of obstruction in all three patients. Thus, the duodenum should be carefully evaluated radiographically in patients with acute gastric dilatation, particularly if there is a known history of malignancy.
A review of 100 routine biphasic upper gastrointestinal examinations revealed focal spiculation of the upper thoracic esophagus as a transient finding in 11 patients (11%) who otherwise had no clinical or radiographic signs of esophageal disease. All 11 patients had remarkably similar findings, with thin (1-2 mm wide), transverse folds or striations above the level of the aortic arch, producing a spiculated or serrated appearance in profile. This focal spiculation should be considered a normal variant in the esophagus on double-contrast radiographs. It is suspected that this phenomenon is related to weakening of peristalsis or localized contraction of the longitudinally oriented muscularis mucosae at the junction of the striated- and smooth-muscle portions of the esophagus. Whatever the explanation, radiologists should be familiar with this finding, so that it is not mistaken for a focal area of esophagitis.
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The authors performed a retrospective study of 50 patients with endoscopically diagnosed duodenitis who had undergone double-contrast upper gastrointestinal (GI) examinations. Duodenitis was diagnosed on the original radiographic reports in six of 37 patients (16%) with mild-to-moderate duodenitis, five of 13 patients (38%) with severe duodenitis, and 11 of 50 patients (22%) with all grades of duodenitis on endoscopy. Subsequent analysis of the films revealed one or more radiologic signs of duodenitis (including folds more than 4 mm in thickness, mucosal nodularity, bulbar deformity, and erosions) in 18 of 37 patients (49%) with mild-to-moderate duodenitis, eight of 13 patients (62%) with severe duodenitis, and 26 of 50 patients (52%) with all grades of duodenitis on endoscopy. In a separate part of the study, the authors identified another 20 patients with radiographically diagnosed duodenitis who had undergone endoscopic examinations. Nine of those 20 patients (45%) had duodenitis on endoscopy. Subsequent analysis of the films revealed one or more signs of duodenitis in 17 patients from this group. Nine of the latter patients (53%) had duodenitis on endoscopy. Using established radiologic criteria for duodenitis, our rate of false-positive and false-negative radiologic diagnoses still was about 50%. Thus, the double-contrast upper GI examination is a relatively unreliable technique for diagnosing duodenitis.
This pictorial essay will explain how to obtain quality double- contrast radiographs during pharyngography, present principles of the interpretation of double-contrast images of the pharynx, and show examples of benign and malignant pharyngeal tumors.
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Human immunodeficiency virus (HIV) infection of the esophagus has recently been implicated as a cause of giant esophageal ulcers in HIV-positive patients with odynophagia. The authors examined four patients in whom esophagograms (one single-contrast and three double-contrast studies) revealed giant, HIV-related ulcers indistinguishable from those of cytomegalovirus (CMV) esophagitis. All four patients had severe odynophagia, one had an associated maculopapular rash, and two became HIV-positive at approximately the time of clinical presentation. In all patients, biopsy samples, brushings, and cultures obtained with endoscopy were negative for CMV or herpes simplex. One patient had positive brushings for candidiasis, but this may have resulted from fungal superinfection of the ulcer. Two patients were treated with orally administered steroids, and all four had swift clinical improvement; symptoms disappeared during an average period of 8.3 days from presentation. HIV-related esophageal ulcers should be distinguished from CMV ulcers, so that appropriate treatment can be initiated in these patients.
A blinded, retrospective study was performed to determine the value of supine abdominal radiographs in diagnosing pneumoperitoneum. Supine films from 44 cases of pneumoperitoneum were randomly interspersed among supine films from 87 control subjects without free air, and the films were reviewed for the presence or absence of various signs of pneumoperitoneum, including Rigler's sign (gas on both sides of the bowel wall), the falciform ligament sign (gas outlining the falciform ligament), the football sign (gas outlining the peritoneal cavity), the inverted-V sign (gas outlining the medial umbilical folds), and the right-upper-quadrant gas sign (localized gas in the right upper quadrant). One or more of these signs were present in 26 cases (59%) of pneumoperitoneum, including the right-upper-quadrant gas sign in 18 cases (41%), Rigler's sign in 14 cases (32%), and the falciform ligament and football signs in one case each (2%). Unfortunately, there were frequent errors in the interpretation of the right-upper-quadrant gas sign and Rigler's sign, with a total of 11 false-positive cases (13%). Further analysis of the true-positive right-upper-quadrant gas signs showed that these gas collections were always triangular or linear with an inferolateral to superomedial orientation and, if triangular, a concave superolateral border. In the true-positive Rigler's signs, the bowel wall thickness ranged from 1 to 8 mm, whereas the false positives all had a bowel wall thickness of 1 mm or less. Proper interpretation of the various signs of pneumoperitoneum on supine films should lead to more accurate diagnosis of this condition.
Total gastrectomy and esophagojejunostomy is an increasingly common operation that is associated with a variety of early and late postoperative complications. Between 1980 and 1990, 26 patients at our hospital who underwent this surgery (19 Roux-en-Y esophagojejunostomies and seven loop esophagojejunostomies) had postoperative upper gastrointestinal studies with water-soluble contrast material or barium. The studies were performed during the early postoperative period (within 30 days after surgery) in seven patients, the late postoperative period (more than 30 days after surgery) in seven patients, or both in 12 patients. Five patients (19%) had anastomotic leaks, four involving the esophagojejunal anastomosis and one the blind-ending jejunal limb. Five patients (19%) had transient narrowing of the esophagojejunal anastomosis during the early postoperative period, probably due to acute postoperative edema and spasm. Six patients (23%) had narrowing of the esophagojejunal anastomosis during the late postoperative period due to anastomotic strictures (three patients) or recurrent tumor (three patients). Alkaline reflux esophagitis was found in three (43%) of seven patients who had a loop esophagojejunostomy. However, two (11%) of 19 patients with a Roux-en-Y esophagojejunostomy had relatively long strictures in the distal esophagus, apparently due to scarring from alkaline reflux esophagitis. Two patients (8%) had an afferent loop obstruction due to metastatic tumor and postsurgical scarring. Radiologists need to be familiar with the normal postoperative radiologic appearances and the radiologic findings of early and late complications associated with this procedure.
Colonoscopic polypectomy is the usual treatment for an adenomatous colorectal polyp. We report a case of a sessile tubulovillous adenoma in the rectosigmoid colon disappearing during a course of radiation therapy for an unrelated cervical cancer. This case report illustrates that at least some colonic polyps are radiosensitive and can be eradicated during radiation therapy.
The presence of isolated gastric varices without esophageal varices is thought to be highly suggestive of splenic vein obstruction. A review of our radiologic files revealed 14 patients with isolated gastric varices on barium studies performed during the past 10 years. Eight of the 14 patients had adequate clinical and/or radiologic follow-up to suggest the pathophysiology of the varices. Seven had evidence of portal hypertension, and the remaining patient had evidence of splenic vein obstruction. Six patients had signs of upper gastrointestinal (GI) bleeding. Double-contrast upper GI examinations revealed thickened, tortuous fundal folds in 6 patients and a lobulated fundal mass in 2. Thus, most patients with isolated gastric varices have portal hypertension rather than splenic vein obstruction as the underlying cause.
Motility of the pharyngoesophageal segment (PES) was monitored by cineradiography (50 frames a second) during barium swallow and analyzed by a computerized topographic mapping of sagittal wall motion. Through measurement of wall displacement on 20 consecutive levels of the PES, distention, contraction, and peristalsis were studied. Topographic mapping of three patients with normal PES motility, delayed opening of the cricopharyngeus, and incomplete opening of the cricopharyngeus, was performed. These topographic mappings show that "narrowing" at the level of the cricopharyngeus reflects expansion of the hypopharynx and cervical esophagus around the cricopharyngeus, rather than a true narrowing. In addition, analysis of wall motion demonstrated that abnormality of the circopharyngeus is often associated with abnormality of wall motion in the adjoining hypopharynx and cervical esophagus. Thus, topographic mapping of the cricopharyngeus is of value because it enables detailed analysis of wall motion during various pathologic conditions.
The authors present a simplified radiographic classification of non-Hodgkin lymphoma involving the small intestine. The classification system is based on radiographic findings in 22 pathologically proved cases of lymphoma involving the small bowel and consists of three major forms: primary, lymphoma complicating celiac disease, and mesenteric nodal. In this series, small bowel lymphoma was evenly distributed in the jejunum and ileum. The most common radiographic patterns were circumferential lesion (seven cases), cavitary lesion (four cases), and mesenteric nodal disease invading the small bowel (seven cases). Obstructive symptoms were usually encountered with the mesenteric nodal form. Lymphoma complicating celiac disease was typified by multiple, thickened, nodular folds involving a segment of proximal small intestine.
During a recent 10-year period, scirrhous tumors of the stomach were diagnosed at upper gastrointestinal examinations in 27 patients in whom pathologic correlation was available. Nineteen patients underwent double-contrast studies, and eight underwent single-contrast studies. Twenty-two of the 27 patients had primary gastric carcinoma, four had gastric involvement by metastatic breast cancer, and one had antral gastritis and scarring without evidence of malignancy. Although the involved gastric segment often demonstrated only mild loss of distensibility, the presence of a scirrhous tumor was suggested radiographically by distortion of the normal surface pattern of the stomach with mucosal nodularity, spiculation, ulceration, and/or thickened, irregular folds. Ten patients had localized lesions involving the gastric fundus and/or body rather than the classic form of linitis plastica involving the distal stomach. Furthermore, endoscopy had significant limitations in confirming this diagnosis, as findings from brushings or biopsies were positive for malignancy in only 14 of 20 patients (70%). Radiologists should be aware of the frequent proximal location of these scirrhous tumors and of the problems of endoscopic diagnosis.
At radiography, hyperplastic polyps classically appear as smooth, sessile elevations less than 5 mm in diameter. However, a retrospective review of double-contrast barium enema studies in 22 patients with 31 pathologically proved hyperplastic polyps revealed an average polyp size of 7.3 mm, with a range of 3-21 mm. Fifteen polyps (48%) were 2-5 mm, 12 (39%) were 6-10 mm, and four (13%) were greater than 10 mm in diameter. Twenty-nine polyps (94%) were sessile, and two polyps (6%) were pedunculated. Twenty-three polyps (74%) had a smooth contour, and eight polyps (26%) were lobulated. Twenty-six of the hyperplastic polyps (84%) were located in the rectosigmoid colon. If the radiologic criteria for an atypical hyperplastic polyp at double-contrast barium enema examination include size greater than 5 mm, lobulation, and/or pedunculation, 16 of the 31 hyperplastic polyps (52%) could be classified as atypical. Thus, radiologists should be aware that many hyperplastic polyps seen at double-contrast barium enema examination do not fit the classic description of a smooth, sessile elevation less than 5 mm in size but instead appear as larger, more lobulated lesions that are indistinguishable from adenomatous polyps.
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The authors retrospectively studied 43 patients suspected of having internal hemorrhoids at double-contrast barium enema examination. At endoscopy, 24 patients (56%) had internal hemorrhoids, four (9%) had other pathologic lesions in the rectum without evidence of hemorrhoids, and 15 (35%) had no reported abnormalities in the rectum. Internal hemorrhoids were found at endoscopy in 10 of 20 patients (50%) with lobulated folds extending 3 cm or less from the anorectal junction and 10 of 13 patients (77%) with multiple submucosal nodules. However, no patients with these characteristic radiographic findings were found to have other pathologic lesions in the rectum that had been mistaken for hemorrhoids at barium enema examination. Conversely, three of four patients with lobulated folds extending more than 3 cm from the anorectal junction and one of six patients with solitary nodules had proctitis or rectal neoplasms. Thus, specific criteria are suggested for the diagnosis of internal hemorrhoids on double-contrast barium enema examinations. Suspected hemorrhoids that do not fulfill these criteria should be evaluated endoscopically to rule out other more serious pathologic lesions in the rectum.