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Extracorporeal shock wave lithotripsy (ESWL) of gall-bladder stones using a piezo-ceramic system
684
CLINICAL RADIOLOGY
RADIOLOGICAL FEATURES OF CHOLANGITIS IN FIVE i PATIENTS WITH ACQUIRED IMMUNE DEFICIENCY SYNDROME (AIDS)
M. McCARTY, A. H. C H O U D H R I and M. H E L B E R T
St Mary's Hospital, London Organisms of the genus Cryptosporidium are parasitic protozoans that may inhabit the gastrointestinal tract of a variety of animals, including man. Although human manifestations are considered to be rare, a moderate self-limiting illness with the cardinal symptoms of diarrhoea and abdominal pains is described in immunocompetent patients. Cryptosporidiosis in immunodeflcient persons however, causes severe prolonged diarrhoea which is refractory to treatment and is a marker of a poor prognosis. Five out of 14 AIDS patients with gastrointestinal cryptosporidiosis in our series developed evidence of cholangitis with abnormal liver function tests and biliary pain. The appearances on ultrasound in all our patients included dilatation of the intra- and extrahepatic bile ducts. Thickening of the duct walls was seen in three patients. Dilatation of the pancreatic duct was noted in one patient. E R C P was performed in one patient, and showed similar findings to the sonographic studies with areas of focal narrowing and dilatation of the bile ducts. None of these patients had any predisposing conditions for cholangitis such as inflammatory bowel disease, thyroid disease, biliary calculi, previous surgery etc. Cryptosporidium was demonstrated, by ZN staining, in the stools of all patients. Rectal biopsy was positive for cryptosporidium in one patient and a positive jejunal aspirate was obtained in one patient. In the patient who underwent E R C P , cryptosporidium was found in the biliary juice. Cytomegalovirus was not a co-pathogen in any case. We believe that the cholangitis in this group of patients was caused by cryptosporidial infection of the biliary tract.
NEW ANGIOGRAPHIC METHODS OF EMBOLISATION OF LIVER TUMOURS S. N. JONES and W. R. LEES
Middlesex Hospital, London The post-embolisation syndrome has been the major complication limiting hepatic arterial embolisation in patients with primary and secondary liver tumours. Latterly, a cluster of papers have demonstrated the prolonged and disproportionate retention of Lipiodol ultrafluid (UF) within hepatic tumours after selective intrahepatic arterial injection. Plain or computed tomography (CT) studies after Lipiodol U F have frequently demonstrated foci of tumour not previously seen on (1) arteriography, (2) scintigraphy, (3) plain or contrast-enhanced CT and (4) ultrasound. The implications of this include (1) a decrease in inappropriate hepatic segmentectomy, (2) cost effective follow-up by abdominal X-ray or CT as Lipiodol is retained for over a year and (3) easy differentiation of tumour from hyperplastic nodules or haemangiomas. Work in progress is presented which involves the selective hepatic arterial injection of Lipiodol U F mixed with doxorubicin in patients with symptoms from unresectable tumour and no other possible effective treatment. Therapeutic results are gauged by subjective and clinical assessment, ultrasound and CT. Only very mild post-embolisation complications have been experienced to date. Indications for and results of treatment, hazards and contraindications are discussed. Our preliminary conclusion is that good palliation can be achieved but there is no firm evidence of increased survival.
the inferior vena cava. All patients had evidence of one or more of these abnormalities. Five of the patients received follow-up scans during treatment. The study shows that the assessment of the progression or regression of the CT appearances, particularly the parenchymal abnormalities, is useful in monitoring the response to treatment in this disorder. EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY (ESWL) OF GALL-BLADDER STONES USING A PIEZO-CERAMIC SYSTEM A. K E I G H T L E Y , K. A. H O O D , J. A. DICK, R. H. D O W L I N G and C. N. M A L L I N S O N
Guy's, Lewisham and London Bridge Hospitals, London ESWL is now well established in the treatment of renal tract calculi. The advent of those 'second generation' lithotripters which use ultrasound to localise the calculi has lead to increased interest in the evaluation of ESWL for gall-bladder stones. Initial experience using a piezo-ceramic lithotripter in 32 patients is presented. Patients suitable for ESWL are those with one to three cholesterol stones greater than 1 cm in diameter in a functioning gall-bladder. These criteria are established with oral cholecystography (OCG) and CT. Treatment requires neither analgesia nor immersion in a water bath. Approximately 4000 shocks are given per treatment and up to five sessions are required for adequate fragmentation. Interval O C G has proved the best means of assessing fragmentation. Adjucant oral bile acid therapy is started at the first treatment and is continued until the patient is stone-free on ultrasound. Lithotripsy was well tolerated in all patients and there were few side-effects in the immediate post-treatment period. It was unsuccessful in four patients. One patient developed acute pancreatitis six weeks after ESWL and a further patient had an episode of cholestasis two months after ESWL, which resolved spontaneously.
STENT INSERTION IN THE MANAGEMENT OF MALIGNANT BILIARY OBSTRUCTION A. F. C A R G I L L
West Hill Hospital, Kent A number of recent papers have suggested, despite evidence to the contrary, that surgery is the best form of management for malignant biliary obstruction. The major underlying pathology is carcinoma of the pancreatic head which is potentially curable in only one case in 10. 'Palliative options include chemotherapy, percutaneous and endoscopic stent insertion and surgery. However,- survival following surgery is no better than that after stent insertion and surgical 30 day mortality is worse. Complications are a feature of any by-pass procedure but all surgical patients may expect a more or less stormy postoperative period. This is in marked contrast to stented cases who have little post-operative discomfort .and are usually rapidly discharged from hospital. Surgery is probably more expensive though there is evidence that the overall cost is about the same for surgical and non surgical management because all patients spend the same amount of time in hospital prior to death. While there are undoubtedly some situations where surgery is mandatory a non-surgical approach would be acceptable in a number of cases. This would be less unpleasent for the patient and would be associated with a lower post-procedure mortality. THE FIRST 3 YEARS: BALLOON DILATION OF BENIGN
THE USE OF COMPUTED T O M O G R A P H Y IN THE DIAGNOSIS AND MANAGEMENT OF THE BUDD-CHIARI SYNDROME
OESOPHAGEAL STRICTURES UNDER X-RAY CONTROL IN THE FIRST 31 PATIENTS
A. B O O T H and A. A D A M
S. W. E. SVENSSON, R. D. D I C K and R. M. K I R K
Hammersmith Hospital, London
Royal Free Hospital, London
The Budd-Chiari syndrome is a rare disorder in which there is partial or complete hepatic vein and/or inferior vena caval occlusion. The pathophysiology of this condition is complex, but in the absence of a congenital abnormality the obstruction to the veins is usually due to tumour, trauma, or thrombosis. We have reviewed the CT appearances of a total of nine patients with this disorder, the diagnosis being proven angiographically in all cases. The CT appearances may include abnormalities of the liver parenchyma, in particular inhomogeneity, with areas of low attenuation in both lobes of the liver. This appearance which is probably due to abnormalities of perfusion, is often less marked or even absent in the caudate lobe which is often enlarged in this condition. There may also be ascites, absence of intrahepatic veins, and visible narrowing of
The results of balloon dilation of benign oesophageal strictures performed under X-ray control are reported in the first thirty one patients treated by this method in this hospital over a 3-year period. Almost all the dilations were performed by one person. The follow up ranges from 6 months to 2.5 years. Twenty-five per cent of the strictures followed previous oesophageal surgery and the remainder were due to reflux oesophagitis. The patients ages ranged from 32 to 88 years. The number of dilations per patient ranged from one to four and for those requiring more than one dilation the time between dilations ranged from 2 weeks to-10 months. Modifications to the technique as a result of our first 3 years experience are described.
CLINICAL RADIOLOGY
RADIOLOGICAL FEATURES OF CHOLANGITIS IN FIVE i PATIENTS WITH ACQUIRED IMMUNE DEFICIENCY SYNDROME (AIDS)
M. McCARTY, A. H. C H O U D H R I and M. H E L B E R T
St Mary's Hospital, London Organisms of the genus Cryptosporidium are parasitic protozoans that may inhabit the gastrointestinal tract of a variety of animals, including man. Although human manifestations are considered to be rare, a moderate self-limiting illness with the cardinal symptoms of diarrhoea and abdominal pains is described in immunocompetent patients. Cryptosporidiosis in immunodeflcient persons however, causes severe prolonged diarrhoea which is refractory to treatment and is a marker of a poor prognosis. Five out of 14 AIDS patients with gastrointestinal cryptosporidiosis in our series developed evidence of cholangitis with abnormal liver function tests and biliary pain. The appearances on ultrasound in all our patients included dilatation of the intra- and extrahepatic bile ducts. Thickening of the duct walls was seen in three patients. Dilatation of the pancreatic duct was noted in one patient. E R C P was performed in one patient, and showed similar findings to the sonographic studies with areas of focal narrowing and dilatation of the bile ducts. None of these patients had any predisposing conditions for cholangitis such as inflammatory bowel disease, thyroid disease, biliary calculi, previous surgery etc. Cryptosporidium was demonstrated, by ZN staining, in the stools of all patients. Rectal biopsy was positive for cryptosporidium in one patient and a positive jejunal aspirate was obtained in one patient. In the patient who underwent E R C P , cryptosporidium was found in the biliary juice. Cytomegalovirus was not a co-pathogen in any case. We believe that the cholangitis in this group of patients was caused by cryptosporidial infection of the biliary tract.
NEW ANGIOGRAPHIC METHODS OF EMBOLISATION OF LIVER TUMOURS S. N. JONES and W. R. LEES
Middlesex Hospital, London The post-embolisation syndrome has been the major complication limiting hepatic arterial embolisation in patients with primary and secondary liver tumours. Latterly, a cluster of papers have demonstrated the prolonged and disproportionate retention of Lipiodol ultrafluid (UF) within hepatic tumours after selective intrahepatic arterial injection. Plain or computed tomography (CT) studies after Lipiodol U F have frequently demonstrated foci of tumour not previously seen on (1) arteriography, (2) scintigraphy, (3) plain or contrast-enhanced CT and (4) ultrasound. The implications of this include (1) a decrease in inappropriate hepatic segmentectomy, (2) cost effective follow-up by abdominal X-ray or CT as Lipiodol is retained for over a year and (3) easy differentiation of tumour from hyperplastic nodules or haemangiomas. Work in progress is presented which involves the selective hepatic arterial injection of Lipiodol U F mixed with doxorubicin in patients with symptoms from unresectable tumour and no other possible effective treatment. Therapeutic results are gauged by subjective and clinical assessment, ultrasound and CT. Only very mild post-embolisation complications have been experienced to date. Indications for and results of treatment, hazards and contraindications are discussed. Our preliminary conclusion is that good palliation can be achieved but there is no firm evidence of increased survival.
the inferior vena cava. All patients had evidence of one or more of these abnormalities. Five of the patients received follow-up scans during treatment. The study shows that the assessment of the progression or regression of the CT appearances, particularly the parenchymal abnormalities, is useful in monitoring the response to treatment in this disorder. EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY (ESWL) OF GALL-BLADDER STONES USING A PIEZO-CERAMIC SYSTEM A. K E I G H T L E Y , K. A. H O O D , J. A. DICK, R. H. D O W L I N G and C. N. M A L L I N S O N
Guy's, Lewisham and London Bridge Hospitals, London ESWL is now well established in the treatment of renal tract calculi. The advent of those 'second generation' lithotripters which use ultrasound to localise the calculi has lead to increased interest in the evaluation of ESWL for gall-bladder stones. Initial experience using a piezo-ceramic lithotripter in 32 patients is presented. Patients suitable for ESWL are those with one to three cholesterol stones greater than 1 cm in diameter in a functioning gall-bladder. These criteria are established with oral cholecystography (OCG) and CT. Treatment requires neither analgesia nor immersion in a water bath. Approximately 4000 shocks are given per treatment and up to five sessions are required for adequate fragmentation. Interval O C G has proved the best means of assessing fragmentation. Adjucant oral bile acid therapy is started at the first treatment and is continued until the patient is stone-free on ultrasound. Lithotripsy was well tolerated in all patients and there were few side-effects in the immediate post-treatment period. It was unsuccessful in four patients. One patient developed acute pancreatitis six weeks after ESWL and a further patient had an episode of cholestasis two months after ESWL, which resolved spontaneously.
STENT INSERTION IN THE MANAGEMENT OF MALIGNANT BILIARY OBSTRUCTION A. F. C A R G I L L
West Hill Hospital, Kent A number of recent papers have suggested, despite evidence to the contrary, that surgery is the best form of management for malignant biliary obstruction. The major underlying pathology is carcinoma of the pancreatic head which is potentially curable in only one case in 10. 'Palliative options include chemotherapy, percutaneous and endoscopic stent insertion and surgery. However,- survival following surgery is no better than that after stent insertion and surgical 30 day mortality is worse. Complications are a feature of any by-pass procedure but all surgical patients may expect a more or less stormy postoperative period. This is in marked contrast to stented cases who have little post-operative discomfort .and are usually rapidly discharged from hospital. Surgery is probably more expensive though there is evidence that the overall cost is about the same for surgical and non surgical management because all patients spend the same amount of time in hospital prior to death. While there are undoubtedly some situations where surgery is mandatory a non-surgical approach would be acceptable in a number of cases. This would be less unpleasent for the patient and would be associated with a lower post-procedure mortality. THE FIRST 3 YEARS: BALLOON DILATION OF BENIGN
THE USE OF COMPUTED T O M O G R A P H Y IN THE DIAGNOSIS AND MANAGEMENT OF THE BUDD-CHIARI SYNDROME
OESOPHAGEAL STRICTURES UNDER X-RAY CONTROL IN THE FIRST 31 PATIENTS
A. B O O T H and A. A D A M
S. W. E. SVENSSON, R. D. D I C K and R. M. K I R K
Hammersmith Hospital, London
Royal Free Hospital, London
The Budd-Chiari syndrome is a rare disorder in which there is partial or complete hepatic vein and/or inferior vena caval occlusion. The pathophysiology of this condition is complex, but in the absence of a congenital abnormality the obstruction to the veins is usually due to tumour, trauma, or thrombosis. We have reviewed the CT appearances of a total of nine patients with this disorder, the diagnosis being proven angiographically in all cases. The CT appearances may include abnormalities of the liver parenchyma, in particular inhomogeneity, with areas of low attenuation in both lobes of the liver. This appearance which is probably due to abnormalities of perfusion, is often less marked or even absent in the caudate lobe which is often enlarged in this condition. There may also be ascites, absence of intrahepatic veins, and visible narrowing of
The results of balloon dilation of benign oesophageal strictures performed under X-ray control are reported in the first thirty one patients treated by this method in this hospital over a 3-year period. Almost all the dilations were performed by one person. The follow up ranges from 6 months to 2.5 years. Twenty-five per cent of the strictures followed previous oesophageal surgery and the remainder were due to reflux oesophagitis. The patients ages ranged from 32 to 88 years. The number of dilations per patient ranged from one to four and for those requiring more than one dilation the time between dilations ranged from 2 weeks to-10 months. Modifications to the technique as a result of our first 3 years experience are described.