X-ray and ultrasonic diagnosis of noninflammatory benign diseases of the gallbladder]

The author analyzes the results of x-ray (cholecystography) and ultrasonic examinations carried out in patients with noninflammatory benign diseases of the gallbladder (71 with cholesterosis and 28 with adenomyomatosis). X-ray and ultrasonic symptoms of these conditions are presented and the diagnostic potentialities of both methods in the detection of such diseases assessed. The author considers ultrasonic scanning the method of choice for the diagnosis of any forms of gallbladder cholesterosis, whereas an x-ray examination appears to be informative only in a polypous form of the disease. X-ray contrast examination is preferable for the recognition of gallbladder adenomyomatosis, for it presents a clear-cut pattern characteristic of each form of this condition, whereas ultrasonic symptoms of such involvement are nonspecific.     

Algorithms of x-ray and ultrasonic diagnoses in urology]

Roentgenourologic methods and ultrasonic scanning (USS) should be combined in the radiologic diagnosis of urologic diseases. USS should be the first stage of examinations of urologic patients, and its results should be taken into account when planning and carrying out excretory urography. USS can be repeated before more sophisticated roentgenourologic examinations in order to single out the "zones of interest"; special programmes are possible for the purpose-pharmacoechography, dopplerography, etc. Development of tentative algorithms of x-ray and ultrasonic diagnosis of the major urologic diseases will help optimize the diagnostic process.     

Radiodiagnosis of kidney diseases in a municipal hospital]

Ultrasonic (US) examinations of the urinary tract of 2384 patients have revealed pathologic shifts in 725 cases; x-ray examinations had to be carried out in 632 of these to specify the diagnosis. X-Ray and US-based radiodiagnosis of a wide spectrum of renal diseases, carried out at a common municipal hospital, promotes a better diagnosis. Employment of US examinations as a screening method helps recognize renal hypoplasia, cystic diseases, and an acute inflammatory process, renal carbuncle, fairly well. The diagnosis of other renal abnormalities, urolithiasis, hydronephrotic transformations, tumors and injuries still has to be specified by routine x-ray methods.     

Ultrasonographic guidance in diagnostic and therapeutic interventions in diseases of the internal organs

A hundred fifty four invasive diagnostic and therapeutical interventions were made in patients with diseases of the abdomen and retroperitoneal space under ultrasonographic guidance. Various biopsies were performed in 139 patients; positive results were achieved in 120 (86.3%) cases. In 15 patients, diagnostic biopsies were combined with therapeutical interventions, such as aspiration of cysts in the liver (n = 3) and kidney (n = 2); drainage of abscesses in the abdomen (n = 5) and liver (n = 5). Fourteen patients with mechanical jaundice caused by extrahepatic bile duct tumors or pancreatic head cancer underwent percutaneous transhepatic cholecystocholangiography followed by external drainage. Percutaneous transhepatic drainage of the gallbladder was made in 1 patient with acute cholecystitis.     

Invasive interventions guided by computerized tomography in the diagnosis and treatment of diseases of the internal organs

Diagnostic punctures under CT guidance were made in 544 patients with diseases of the chest (n = 303), abdomen (n = 149), and retroperitoneal space (n = 92). In 87 patients, diagnostic punctures were combined with therapeutical manipulations and included aspiration and drainage of visceral organ cysts and abscesses. The proposed procedure of diagnostic biopsies under CT guidance could ascertain the morphological nature of a lesion in 90.1% of cases prior to treatment. Therapeutical aspirations and drainage of visceral cysts and abscesses under CT guidance resulted in their complete recovery in 97.8 and 85.7% of cases, respectively. Diagnostic and therapeutical interventions under CT guidance caused complications in 6.9% of cases. At diagnostic biopsy, pneumothorax is the most frequent complication *5.3%), and lung tissue hemorrhage along the puncture needle passage is the less frequent (1.3%). The use of therapeutical interventions developed complications in 1.1% of cases.     

Splenic Subcapsular Hematoma—Ultrasonic Diagnosis

In five patients with varying histories of blunt abdominal trauma, examinations were carried out with ultrasonography and other imaging modalities. In all five patients, large, fluid-filled masses were noted in the left upper quadrant. Two patients had nonpalpable hematomas, but examinations were done because of history and vague clinical symptoms. Three patients had palpable masses. In all five patients there was surgical confirmation of the ultrasonic findings, and all recovered without complications. Ultrasonic tomography offers a convenient noninvasive method for assessing suspected splenic hematoma and can also exclude the possibility in a careful examination.     

Ultrasonic diagnosis of non-Hodgkin's lymphoma]

Analyzes the results of ultrasonic examinations of 111 patients with various forms of non-Hodgkin's lymphomas. Reviews ultrasonic semeiotics of non-Hodgkin's lymphadenopathy of the abdominal cavity and retroperitoneal space and of extranodal variants of lymphoma course (with involvement of the spleen and stomach). Suggests the most safe method for precision diagnostic aspiration biopsy of the spleen monitored by ultrasound. The author considers ultrasonic examination to be a valuable method for the diagnosis of non-Hodgkin's lymphomas; it is economic, rapid, safe, permits a simultaneous assessment of the status of many organs and systems. The results of ultrasonic examinations should be assessed in complex with the results of other diagnostic methods. Ultrasonic examination should be considered as a method of choice for monitoring patients with diagnosed non-Hodgkin's lymphoma.     

Fine needle aspiration biopsy of the spleen in pyrexia of unknown origin

To evaluate the diagnostic utility, value and potential risk of fine needle aspiration biopsy of spleen (sFNAB) in patients with splenomegaly in pyrexia of unknown origin (PUO), a retrospective analysis of medical records and cytological material of 31 patients on whom FNAB was performed between April 1994 and October 1997 was done. The patients were HIV- and presented with PUO. All other relevant investigations were negative. The spleen was either palpable or detected to have space-occupying lesions on ultrasonography (USG). The splenic aspirates showed tuberculosis in 11 patients (35.4%) and inconclusive or reactive changes in nine patients (25.8%). One case out of this group proved to be Kaposi's sarcoma on autopsy. The other diseases encountered were leishmaniasis (n = 3), non-Hodgkin's lymphoma (n = 4), fungal infections (n = 2), Hodgkin's lymphoma (n = 1). The patients who were diagnosed as having tuberculosis had epithelioid cells, giant cells, necrosis and inflammatory cells in various combinations. AFB positivity was 63.6%. The other cases which showed granulomas but no AFB were diagnosed on empirical grounds and all responded to the anti-tuberculosis therapy. No complications were encountered with the procedure. Therefore the authors conclude that sFNAB is rewarding in patients where all other non-invasive modalities of diagnosis have failed.     

The sequence of interventions in pancreatic cavities

Schemes for the sequence of therapeutic interventions were worked out based on experience in the recognition of 56 pancreatic cavitations (cysts, abscesses), US-assisted diagnostic punctures, 28 external drainages of the cavities (mainly prolonged catheterization), 4 diagnostic and therapeutic transcutaneous wirsungographies. The authors also worked out recommendations for a choice of instruments for prolonged external transcutaneous drainage of pancreatic cysts and abscesses, cleansing of the cavity and its sclerosing, inoperative cystogastrostomy between a cyst and a stomach stent.     

Fine-needle Aspiration Biopsy of Spleen in Diagnosis of Generalized Amyloidosis

Fine-needle aspiration biopsy of the spleen was performed on 18 patients shown to have amyloid deposits in other organs and on 17 control patients being investigated for proteinuria. Of the 18 patients with amyloid disease smears of splenic aspirate were positive in all cases, renal biopsy was positive in 16 out of 16 cases, and rectal biopsy was positive in seven out of 11 cases. None of the splenic smears were positive in the 17 control patients and no amyloid was found in the kidney in 15 of these patients on whom renal biopsy was performed. Splenic aspirate biopsy seems to be a simple and safe procedure for the diagnosis of amyloidosis. It is as accurate as renal biopsy and more accurate than rectal biopsy.     

Hepatosplenic candidiasis, a late manifestation of Candida septicaemia in neutropenic patients with haematologic malignancies

Systemic candidiasis with Candida-induced abscesses, predominantly in the liver and the spleen, was diagnosed in 27 patients with haematologic malignancies after intensive cytostatic therapy. Specific features included septic fever unresponsive to antimicrobial therapy, hepatosplenomegaly with multiple lesions in the liver and spleen (diameter up to 2 cm) as detected by computed tomography (CT) or ultrasound, and an elevation in liver enzymes. During treatment, induced neutropenia, hepatic and splenic foci were poorly defined histologically and were not identified by imaging procedures. After granulocyte recovery these foci showed characteristic histological patterns. Ultrasound and/or CT investigations of the abdomen now revealed characteristic lesions in the liver and the spleen. Gamma-GT and alkaline phosphatase were early indicators of hepatic involvement in Candida septicaemia and were often already elevated in aplasia.     

Primary retroperitoneal mucinous cystadenoma of borderline malignancy in a male patient. Case report and review of the literature

The spleen is an infrequent site for metastatic lesions, and solitary splenic metastases from squamous cell carcinoma of the esophagus are very rare: only 4 cases have been reported thus far. These lesions are whitish nodules that are macroscopically and radiologically similar to primary splenic lymphomas. We report a case of metachronous splenic metastases from esophageal cancer and multiple splenic abscesses, which developed nine months after apparently curative esophagectomy without adjuvant chemotherapy. The patient underwent splenectomy dissection followed by adjuvant chemotherapy, but liver and skin metastases developed, and the patient died 9 months later.     

Laparoscopy and laparotomy combined with bone marrow biopsy in staging Hodgkin's disease.

The relative merits of laparoscopy with liver and spleen biopsy and staging laparotomy were studied in 91 unselected patients with Hodgkin''s disease. Laparoscopy with liver and spleen biopsy were combined with needle biopsy of the bone marrow and laparotomy was combined with open bone marrow biopsy. In 65 untreated patients six out of seven with liver or marrow disease, or both, were shown to have extranodal lymphomas in these sites by laparoscopy plus needle marrow biopsy. Among 26 patients who had been treated this finding occurred in six out of 10 patients. Spleen biopsies during laparoscopy detected infiltration by lymphoma in 14 out of 37 (38%) patients with diseases spleens. Morbidity was higher after laparotomy than after laparoscopy. Laparoscopy produced abdominal bleeding secondary to splenic biopsy in two patients. All patients with Hodgkin''s disease should be subjected to laparoscopy plus needle marrow biopsy before undergoing laparotomy.     

Potentialities of transcutaneous and transhepatic cholangiography as a method of studying diseases of the bile excretory system]

Comprehensive examinations of 62 patients with jaundice of obscure origins involved transcutaneous transhepatic cholangiography carried out in all the patients, hepatolymphography in 60 cases, relaxation duodenography in 31, angiography in 41, ultrasonic examination of the liver in 31, endoscopic retrograde pancreatocholangiography in 28 and liver scanning in 19 patients. These studies have extended the knowledge on the biliferous system status in obturation and parenchymatous jaundices and helped define the role of transcutaneous transhepatic cholangiography among the invasive methods of radiologic examinations and pararadiologic methods.     

The management of chylothorax

Chylothorax is readily diagnosed from the characteristic qualities of the effusion. Treatment should initially be conservative, consisting of multiple aspirations followed, if necessary, by suction drainage. Approximately half of the patients will not respond to these measures, and direct ligation and division of the duct is necessary for cure. This operation is most readily carried out through the right chest, the thoracic duct being ligated just above the diaphragm. In cases in which the duct is surrounded by tumor, radiotherapy to the mediastinum is often successful in controlling the reaccumulation of chyle, but irradiation is generally not recommended until after a tissue diagnosis has been made by thoracotomy. Nutritional problems are often concomitants of chylothorax.     

Amebic abscess of the liver

In a review of the records in 50 cases of amebic abscess of the liver observed in the Canal Zone between 1920 and 1945 the following features were noted:Incidence was preponderantly in males and highest in persons between the ages of 20 and 40. None of the patients was under 21 years of age. There was a great variety of complaints at the time of admission to hospital. The most common was pain in the right upper quadrant of the abdomen. Demonstration of either elevated or fixed diaphragm by x-ray film and fluoroscopic examination was useful in diagnosis in a number of cases, but absence of such findings did not rule out abscess of the liver. In some cases there was history of previous dysentery with blood in the stools.One or another of three operative procedures was used for drainage of abscesses in 39 patients. Of the 39, six died; in five of the six, multiple abscesses were present. Emetine hydrochloride was given to all patients.     

Clinical importance of enteric communication with abdominal abscesses.

The dynamics of leucocytes in abdominal abscesses were studied using indium-111 autologous leucocyte scanning in 30 patients. Thirteen patients showing enteric drainage of leucocytes on delayed scans were characterised by a lack of abdominal localising signs and a low detection rate by ultrasound (25%). By contrast, 16 of 17 patients without enteric drainage had abdominal signs, and in these patients ultrasound was associated with a higher detection rate (58%). Despite the presence of an enteric route of drainage for the abscess 10 of the 13 patients needed surgical intervention. These results help explain the wide variation in clinical presentation of abdominal abscesses; suggest that 111In leucocyte scanning should be the initial investigation in those patients without focal signs; and show that formal surgical drainage is needed in patients recognised as having enteric communication with abscesses.     

Prediction of the effect of immunoglobulin therapy in ITP

The correlation between the response to high-dose immunoglobulin therapy (IVIg) and the sequestration pattern of Indium-labeled platelets (In-PLT) in the body was studied in 9 patients with chronic idiopathic thrombocytopenic purpura (ITP). Patients that has prominent platelet sequestration in the spleen responded to IVIg. In these patients, splenic sequestration decreased by 20-30% after IVIg without significant changes in hepatic sequestration. This finding suggests that the blocking of splenic Fc receptors with immunoglobulin minimized the destruction of sensitized platelets. However, patients who had almost equal platelet sequestration in the liver and spleen did not respond to IVIg. In these patients, hepatic sequestration decreased after IVIg, whereas splenic sequestration increased. Thus, it appears that estimating the platelet sequestration pattern using In-PLT is useful for predicting the effects of IVIg.     

THE MANAGEMENT OF CHYLOTHORAX

Chylothorax is readily diagnosed from the characteristic qualities of the effusion. Treatment should initially be conservative, consisting of multiple aspirations followed, if necessary, by suction drainage.Approximately half of the patients will not respond to these measures, and direct ligation and division of the duct is necessary for cure. This operation is most readily carried out through the right chest, the thoracic duct being ligated just above the diaphragm. In cases in which the duct is surrounded by tumor, radiotherapy to the mediastinum is often successful in controlling the reaccumulation of chyle, but irradiation is generally not recommended until after a tissue diagnosis has been made by thoracotomy.Nutritional problems are often concomitants of chylothorax.