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Angiography in acute and obscure lower gastrointestinal bleeding
66
ABSTRACTS
is still disputed. While involved but unenlarged nodes will be overlooked, M R I easily distinguishes enlarged nodes from adjacent structures (particularly blood vessels) and the use of the short tau inversion recovery (STIR) sequence allows high signal intensity nodes to stand out from the background. We reviewed 86 patients undergoing abdominopelvic staging scans for the following carcinomas; cervix (23), bladder (24), prostate (15) and renal cell (17); as well as six cases of teratoma and one lymphoma. Involved lymph nodes were detected on 19 scans. They showed the following signal intensities on the different sequences: medium on T1weighted (slightly higher than skeletal muscle), medium to high on proton density, high on T2-weighted (slightly lower than fat) and very high on STIR. Operation or autopsy in 79 patients confirmed lymph node involvement in 12 cases and absence of involvement in 64. In three cases metastatic tumour was discovered in nodes undetected by MRI. Clinical and C T confirmation only was available in seven cases with M R detected node involvement. M R I appears highly accurate for the detection of involved lymph nodes, specificity being 100%, sensitivity 86%.
PERCUTANEOUS NEPHROSTOMY -- THE RADIOLOGISTS' VIEW C. J. N E W L A N D , E. O. K E H I N D E , T. R. T E R R Y , E. M. W A T K I N and Y. REES
Leicester General Hospital, Leicester Percutaneous nephrostomy (PCN) is an established technique used in the management of renal tract obstruction. This study reviews our experience of PCN over a 3 year period in a teaching hospital providing a district urology and nephrology service; and examines the radiological commitment required to provide this service. One hundred and thirty-seven PCN in 108 patients were reviewed, including six in transplant kidneys. In 39% the PCN was performed outof-hours; 67% involved a consultant radiologist. Catheter placement failed in one case. PCN resulted in no deaths. Complications included bleeding (n = 5), sepsis (n = 7), blocked (n = 12) and displaced catheters (n = 25). The underlying pathology was malignant in 24.7%; 11 of these patients were managed with permanent PCN drainage, and their mean survival was 4.5 months (range 2 h to 2 years). This study confirms that PCN is a relatively safe method of providing urinary diversion. Its use in malignant disease needs to be tailored to individual patients and their prognosis. Providing a P C N service represents a significant commitment from the radiology department in out-of-hours work, senior cover and further intervention to resolve problems of blocked and displaced catheters.
P E R C U T A N E O U S N E P H R O L I T H O T O M Y AS T H E PREFERRED TREATMENT FOR SMALL RENAL CALCULI K. D. M C B R I D E and J. GLAVES
Chesterfield and North Derbyshire Royal Hospital, Chesterfield The usual approach to the treatment of renal stones is primary referral for extra-corporeal shock wave lithotripsy (ECSWL). However, this modality does not guarantee passage of the stone fragments. At our centre the established primary treatment has been percutaneous nephrolithotomy (PCNL) or nephrolithotripsy. One radiologist has performed the entire procedure, from accessing, to PCNL, to lithotripsy and removal, in all cases. The purpose of this presentation is to assess prospectively 5 years of experience with this approach. F r o m January 1986, a total of 65 patients have undergone 72 procedures, either P C N L or percutaneous nephrolithotripsy. These were 43 (63%) males, and the overall average age was 51 years (range 18-70 years). There were 53 (81.5%) patients completely stone-free after therapy. Four patients required a second separate P C N L and one patient required three separate P C N L s before complete clearance. Almost all stones of less than 1.5 cm diameter were removed intact. The reasons for failure of stone removal and the various treatment alternatives will be discussed. The authors feel that, with the increasing use of ECSWL, more radiologists should become proficient in P C N L techniques to complement the former modality. Indeed, as in our series, P C N L may often be the procedure of choice, particularly for stones of tess than 1.5 cm diameter.
C O L O U R D O P P L E R I M A G I N G O F T H E CYSTIC A R T E R Y F. P. M-CGRATH, S. H. LEE and R. G. G I B N E Y
McMaster University Medical Centre, Hamilton, Ontario, Canada Vascular dilatation and petechial haemorrhage has been shown to occur in the gall-bladder wall within 6 h of extracorporeal shock-wave lithotripsy for gall-stones. Theoretically, inflammation of the gallbladder wall, as in acute cholecystitis, should also have an increased vascular supply at some point in its development. In an attempt to establish if an increased blood flow could be demonstrated in these situations colour Doppler flow imaging (CDFI) was used to examine the gall-bladder vascular supply in 30 volunteers, 30 biliary lithotripsy patients pre- and 2 h post-treatment and in 10 cases of acute cholecystitis. A cystic artery waveform was obtained in 24 of the volunteers, 18 pre- and post-lithotripsy patients and in one of 10 patients with acute cholecystitis. The mean pulsatility indices obtained were 1.04 in the volunteers, 0.98 pre- and 1.02 post-lithotripsy. This difference was not statistically significant (P > 0.1). The single waveform identified in the acute cholecystitis group was of low impedance and similar to that obtained in the volunteers. This study shows that the normal gall-bladder blood supply can be consistently identified using C D F I and that there is no appreciable difference in the cystic artery pulsatility index following medium energy shock wave extracorporeal lithotripsy. Preliminary results in acute cholecystitis suggest that flow is decreased below the sensitivity of the colour Doppler imaging system used for this investigation. A N G I O G R A P H Y IN A C U T E AND O B S C U R E L O W E R G A S T R O I N T E S T I N A L BLEEDING K. D. M C B R I D E and A. P. H E M I N G W A Y
Royal Hallamshire Hospital, Sheffield The accuracy of localization of the source of acute gastrointestinal (GI) haemorrhage a n d of chronic obscure GI bleeding remains variable. Angiography has increased this accuracy in critically ill patients and in those where other investigations had proved negative. The purpose of this presentation is to analyse the results of selective mesenteric angiography in these two groups of patients, performed over the past 4 years, at our centre. Overall, 55 patients have undergone angiography for lower GI bleeding, with 28 (50%) males and an average age of 60 years (range 15 85). In 27 studies done as an emergency 19 (70%) were positive and in 28 elective studies 23 (82%) were positive. The commonest finding was angiodysplasia in 19 (35%), i.e. seven (26%) acute and 12 (43%) obscure. Other c o m m o n lesions were bleeding varices (8), bleeding diverticula (4) and malignant lesions (4). Three patients had haemobilia, two of which had successful embolization. Four patients died as a result of haemorrhage and eleven have been lost to follow up. The remaining 40 have had an average review of 1 year. Ten (18%) patients rebled and 28 (50%) underwent operative treatment as a result of angiographic findings. This study reiterates the importance of a readily available angiography service. It also demonstrates the necessity for early angiography in patients with obscure GI blood loss. T H E VALUE O F A N T E R O P O S T E R 1 O R STRESS P R O C T O G R A P H Y IN T H E DIAGNOSIS OF I N T R A - A N A L INTUSSUSCEPTION OF THE RECTUM S. M C G E E and C. I. B A R T R A M
St Mark's Hospital, London The diagnosis of intra-anal intussusception (IAI) is unique to evacuation proctography (EP), though the diagnostic criteria on routine lateral proctography are imprecise. In 39 patients (35 female, mean age 46 years, range 20-78 years) anteroposterior (AP) stress proctography (films during rest and straining) in the erect position with the rectum empty, was performed following routine lateral EP. The rectal ampulla was found to collapse into 2-3 folds lying in the coronal plane. IAI was diagnosed in eight patients on lateral EP. A P stress proctography revealed rectal fold prolapse into the anal canal during straining in seven of these eight patients, and in four of the remaining 31 cases. Fold thickness was greater in the 12/39 cases diagnosed as IAI (15.2 m m vs 10.6 m m , P < 0.05). There was no significant difference in fold length (2.6 cm vs 2.0 cm). A change in the angle between the fold and the anal canal during straining was observed in all patients, but was significantly greater with IAI (48.2 ° vs 4.0 °, P<0.01). This study suggests that IAI is more accurately defined on AP stress proctography. Lateral proctography m a y miss 33% of IAI, and should be supplemented by AP stress proctography to exclude intussusception.
ABSTRACTS
is still disputed. While involved but unenlarged nodes will be overlooked, M R I easily distinguishes enlarged nodes from adjacent structures (particularly blood vessels) and the use of the short tau inversion recovery (STIR) sequence allows high signal intensity nodes to stand out from the background. We reviewed 86 patients undergoing abdominopelvic staging scans for the following carcinomas; cervix (23), bladder (24), prostate (15) and renal cell (17); as well as six cases of teratoma and one lymphoma. Involved lymph nodes were detected on 19 scans. They showed the following signal intensities on the different sequences: medium on T1weighted (slightly higher than skeletal muscle), medium to high on proton density, high on T2-weighted (slightly lower than fat) and very high on STIR. Operation or autopsy in 79 patients confirmed lymph node involvement in 12 cases and absence of involvement in 64. In three cases metastatic tumour was discovered in nodes undetected by MRI. Clinical and C T confirmation only was available in seven cases with M R detected node involvement. M R I appears highly accurate for the detection of involved lymph nodes, specificity being 100%, sensitivity 86%.
PERCUTANEOUS NEPHROSTOMY -- THE RADIOLOGISTS' VIEW C. J. N E W L A N D , E. O. K E H I N D E , T. R. T E R R Y , E. M. W A T K I N and Y. REES
Leicester General Hospital, Leicester Percutaneous nephrostomy (PCN) is an established technique used in the management of renal tract obstruction. This study reviews our experience of PCN over a 3 year period in a teaching hospital providing a district urology and nephrology service; and examines the radiological commitment required to provide this service. One hundred and thirty-seven PCN in 108 patients were reviewed, including six in transplant kidneys. In 39% the PCN was performed outof-hours; 67% involved a consultant radiologist. Catheter placement failed in one case. PCN resulted in no deaths. Complications included bleeding (n = 5), sepsis (n = 7), blocked (n = 12) and displaced catheters (n = 25). The underlying pathology was malignant in 24.7%; 11 of these patients were managed with permanent PCN drainage, and their mean survival was 4.5 months (range 2 h to 2 years). This study confirms that PCN is a relatively safe method of providing urinary diversion. Its use in malignant disease needs to be tailored to individual patients and their prognosis. Providing a P C N service represents a significant commitment from the radiology department in out-of-hours work, senior cover and further intervention to resolve problems of blocked and displaced catheters.
P E R C U T A N E O U S N E P H R O L I T H O T O M Y AS T H E PREFERRED TREATMENT FOR SMALL RENAL CALCULI K. D. M C B R I D E and J. GLAVES
Chesterfield and North Derbyshire Royal Hospital, Chesterfield The usual approach to the treatment of renal stones is primary referral for extra-corporeal shock wave lithotripsy (ECSWL). However, this modality does not guarantee passage of the stone fragments. At our centre the established primary treatment has been percutaneous nephrolithotomy (PCNL) or nephrolithotripsy. One radiologist has performed the entire procedure, from accessing, to PCNL, to lithotripsy and removal, in all cases. The purpose of this presentation is to assess prospectively 5 years of experience with this approach. F r o m January 1986, a total of 65 patients have undergone 72 procedures, either P C N L or percutaneous nephrolithotripsy. These were 43 (63%) males, and the overall average age was 51 years (range 18-70 years). There were 53 (81.5%) patients completely stone-free after therapy. Four patients required a second separate P C N L and one patient required three separate P C N L s before complete clearance. Almost all stones of less than 1.5 cm diameter were removed intact. The reasons for failure of stone removal and the various treatment alternatives will be discussed. The authors feel that, with the increasing use of ECSWL, more radiologists should become proficient in P C N L techniques to complement the former modality. Indeed, as in our series, P C N L may often be the procedure of choice, particularly for stones of tess than 1.5 cm diameter.
C O L O U R D O P P L E R I M A G I N G O F T H E CYSTIC A R T E R Y F. P. M-CGRATH, S. H. LEE and R. G. G I B N E Y
McMaster University Medical Centre, Hamilton, Ontario, Canada Vascular dilatation and petechial haemorrhage has been shown to occur in the gall-bladder wall within 6 h of extracorporeal shock-wave lithotripsy for gall-stones. Theoretically, inflammation of the gallbladder wall, as in acute cholecystitis, should also have an increased vascular supply at some point in its development. In an attempt to establish if an increased blood flow could be demonstrated in these situations colour Doppler flow imaging (CDFI) was used to examine the gall-bladder vascular supply in 30 volunteers, 30 biliary lithotripsy patients pre- and 2 h post-treatment and in 10 cases of acute cholecystitis. A cystic artery waveform was obtained in 24 of the volunteers, 18 pre- and post-lithotripsy patients and in one of 10 patients with acute cholecystitis. The mean pulsatility indices obtained were 1.04 in the volunteers, 0.98 pre- and 1.02 post-lithotripsy. This difference was not statistically significant (P > 0.1). The single waveform identified in the acute cholecystitis group was of low impedance and similar to that obtained in the volunteers. This study shows that the normal gall-bladder blood supply can be consistently identified using C D F I and that there is no appreciable difference in the cystic artery pulsatility index following medium energy shock wave extracorporeal lithotripsy. Preliminary results in acute cholecystitis suggest that flow is decreased below the sensitivity of the colour Doppler imaging system used for this investigation. A N G I O G R A P H Y IN A C U T E AND O B S C U R E L O W E R G A S T R O I N T E S T I N A L BLEEDING K. D. M C B R I D E and A. P. H E M I N G W A Y
Royal Hallamshire Hospital, Sheffield The accuracy of localization of the source of acute gastrointestinal (GI) haemorrhage a n d of chronic obscure GI bleeding remains variable. Angiography has increased this accuracy in critically ill patients and in those where other investigations had proved negative. The purpose of this presentation is to analyse the results of selective mesenteric angiography in these two groups of patients, performed over the past 4 years, at our centre. Overall, 55 patients have undergone angiography for lower GI bleeding, with 28 (50%) males and an average age of 60 years (range 15 85). In 27 studies done as an emergency 19 (70%) were positive and in 28 elective studies 23 (82%) were positive. The commonest finding was angiodysplasia in 19 (35%), i.e. seven (26%) acute and 12 (43%) obscure. Other c o m m o n lesions were bleeding varices (8), bleeding diverticula (4) and malignant lesions (4). Three patients had haemobilia, two of which had successful embolization. Four patients died as a result of haemorrhage and eleven have been lost to follow up. The remaining 40 have had an average review of 1 year. Ten (18%) patients rebled and 28 (50%) underwent operative treatment as a result of angiographic findings. This study reiterates the importance of a readily available angiography service. It also demonstrates the necessity for early angiography in patients with obscure GI blood loss. T H E VALUE O F A N T E R O P O S T E R 1 O R STRESS P R O C T O G R A P H Y IN T H E DIAGNOSIS OF I N T R A - A N A L INTUSSUSCEPTION OF THE RECTUM S. M C G E E and C. I. B A R T R A M
St Mark's Hospital, London The diagnosis of intra-anal intussusception (IAI) is unique to evacuation proctography (EP), though the diagnostic criteria on routine lateral proctography are imprecise. In 39 patients (35 female, mean age 46 years, range 20-78 years) anteroposterior (AP) stress proctography (films during rest and straining) in the erect position with the rectum empty, was performed following routine lateral EP. The rectal ampulla was found to collapse into 2-3 folds lying in the coronal plane. IAI was diagnosed in eight patients on lateral EP. A P stress proctography revealed rectal fold prolapse into the anal canal during straining in seven of these eight patients, and in four of the remaining 31 cases. Fold thickness was greater in the 12/39 cases diagnosed as IAI (15.2 m m vs 10.6 m m , P < 0.05). There was no significant difference in fold length (2.6 cm vs 2.0 cm). A change in the angle between the fold and the anal canal during straining was observed in all patients, but was significantly greater with IAI (48.2 ° vs 4.0 °, P<0.01). This study suggests that IAI is more accurately defined on AP stress proctography. Lateral proctography m a y miss 33% of IAI, and should be supplemented by AP stress proctography to exclude intussusception.