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C ase History A 52-year-old woman presented to the emergency department with an acute onset of severe abdominal cramps, feculent vomiting. and a fever of 103#{176}F (39#{176}C). Her medical history was significant: an appendectomy, a cholecystectomy, and an oophorectomy. A clinical diagnosis of small-bowel obstruction was made. A radiograph of the abdomen revealed dilated, fluid-filled smallbowel loops that confirmed the diagnosis. A chest radiograph revealed lung consolidation and a moderate-sized right pleural effusion (Fig. 1A). The emergency department resident performed a diagnostic thoracentesis without image guidance. Cloudy fluid was obtained. Laboratory analysis of the pleural fluid identifled 3500 WBC/pJ with a differential of 73% polymorphonuclear leukocytes. a pH of 7.15, and a glucose level of 31 mg/dl. An immediate Gram’s stain revealed no organisms. The patient was begun on IV antibiotics empirically that included 400 mg of clindamycin every 8 hr, 240 mg of gentamicin every 24 hr. and 1 g of eiythromycin every 6 hr. Subsequent cultures revealed no bacterial growth. A clinical diagnosis of empyema was made. What criteria are used to make this diagnosis, and do these criteria assist in selecting the appropriate treatment? Dr. Mueller. We employ the widely used criteria defined by Light [ I ] in differentiating patients with simple parapneumonic effusions from those with empyemas. The diagnosis of empyema by Light’s criteria requires one of the following features to be present: gross pus. organisms on Gram’s stain, a pH below 7.0, or a glucose level below 40 mg/dl [2]. Light went on to describe three stages in the evolution of empyema. The first is the exudative stage, which occurs when a focus of infection con

A 22-year-old man underwent an elective laparoscopic cholecystectomy at an outside hospital for recurrent right upper quadrant pain and gallstones. The day after surgery he had bile leakage from an external surgical drain and underwent open exploration. At surgery he was found to have a common duct laceration; a choledochojejunostomy with a T tube bridging the anastomosis was performed. Postoperatively, he continued to have a bile leak from a Jackson-Pratt surgical drain and was transferred to the Massachusetts General Hospital. A T-tube cholangiogram was performed that showed a small bile leak from the choledochojejunostomy site. He was managed conservatively, and no further leakage was identified on a repeat T-tube cholangiognam 7 days later. He was discharged, and the T tube was removed after 6 weeks. Seven months later he experienced the onset of sharp constant right upper quadrant pain, nausea, and vomiting. He was seen in the emergency room with a fever of 1 02#{176}F, mild jaundice, and liver function tests significant for a bilirubin of 5.2 mg/dl, an AST (aspartate aminotransferase) of 1 94 IU per liter, an ALT (alanine aminotransferase) of 323 lU per liter, and an alkaline phosphatase of 1 61 IU per liter. A WBC count was normal. He was admitted to the hospital and placed on IV fluids, ampicillin, gentamicin, and metronidazole. The next morning a night upper quadrant sonogram showed mildly dilated intrahepatic ducts. A tnanshepatic cholangiogram and biliany drainage were performed. Contrast injection outlined a stricture at the choledochojejunal anastomotic site and mild intrahepatic duct dilatation (Fig. 1). A percutaneous biliary drainage was attempted; the stricture could not be passed, despite multiple attempts with guidewires, and so temporary external drainage was provided with a 7-French pigtail catheter.

The purpose of this study was to develop an algorithm using CT and chemical-shift MR imaging for the characterization of adrenal masses in patients with a primary cancer and no other evidence of metastatic disease.Thirty-three patients with 37 adrenal masses (19 metastases, 18 adenomas), all of whom had a known primary cancer, were studied with noncontrast CT and chemical-shift MR imaging (1.5 T). Lesion size and density in Hounsfield units (H) were determined by CT. Adrenal signal intensity normalized to that of spleen was used to calculate adrenal-spleen ratio (ASR), defined as the percentage of signal remaining in the opposed-phase image relative to the in-phase image. Lesions less than or equal to 0 H were classified as benign, lesions greater than 20 H were regarded as malignant, and lesions between 0 and 20 H were regarded as indeterminate. Diagnoses were confirmed by biopsy (for 19 lesions) or by follow-up imaging (for 18 lesions). An imaging algorithm was derived by determining the relative value of CT and MR imaging for diagnosing the lesions. The reimbursement rates for CT-guided biopsy and MR imaging of the abdomen were obtained from Medicare.All 13 lesions of 0 or less H were correctly classified as benign by CT. ASR was less than 70 in 10 of these 13. In another 13 lesions, H was greater than 20; all were malignant and all had an ASR greater than 80. Of 11 CT-indeterminate lesions, four of five adenomas had an ASR less than 70, and four of six metastases had an ASR greater than 80. Two malignant lesions had ASRs between 70 and 80 and were diagnosed by biopsy findings. One CT-indeterminate adenoma had an ASR of 84 and was diagnosed by biopsy findings. The reimbursement rate by Medicare is similar for CT-guided biopsy with pathologic interpretation and for MR imaging of the abdomen.An algorithm was developed for diagnosis of adrenal lesions that uses the density reading on noncontrast CT as the first step, with chemical-shift MR imaging for CT-indeterminate lesions. In this algorithm, lesions of 0 H or less may be regarded as benign and further work-up is not required. Lesions with a density greater than 20 H are likely malignant and should be biopsied when the result will influence management. For CT-indeterminate lesions, we recommend chemical-shift MR imaging. An ASR threshold of 70 indicates a benign lesion, and no further workup is required in these patients. Lesions with an ASR greater than 70 should have a biopsy performed, depending on the clinical situation. The above algorithm is cost-effective and reduces the number of biopsies required without reducing the sensitivity of detecting malignant lesions.

The purpose of this study was to compare the safety and efficacy of transpleural and extrapleural approaches for draining left subphrenic abscesses in patients who have had splenectomy.Twenty-five patients who had percutaneous catheter drainage (28 drainages) of postsplenectomy fluid collections were studied. Twenty drainages were transpleural and eight were extrapleural. In eight of the 20 transpleural drainages, it was elected to place the catheter transpleurally. In the remaining 12 patients, catheter drainage was judged to be transpleural on review, despite efforts to use an extrapleural approach.Sixteen of 18 patients who had transpleural percutaneous drainage and six of seven patients who had true extrapleural (subcostal) percutaneous drainage were cured by catheter drainage requiring no further intervention. The mean number of days of drainage was not significantly different (p.05) for the group drained transpleurally (mean, 18 days; range, 1-90 days) versus the group drained extrapleurally (mean, 20 days; range, 6-43 days). Complications (pneumothorax) requiring treatment were seen in two patients in whom a transpleural approach was used and in none of the patients in whom an extrapleural approach was used. Complications that did not require treatment were seen in four further patients drained transpleurally. These were inadvertent placement of catheter into pleural space (two patients) and pneumothorax not requiring treatment (two patients). No patient had an empyema.Transpleural drainage of left subphrenic collections occurring after splenectomy is associated with a slightly increased complication rate but has a success rate similar to that of extrapleural drainage.

The purposes of this study were to evaluate the ability of chemical shift MR imaging to differentiate 1- to 5-cm adrenal adenomas from metastases and to compare subjective interpretation with several different quantitative measures.Forty-three patients with 46 proved adrenal lesions (28 adenomas and 18 metastases) had MR imaging with a gradient-echo breath-hold technique and echo time varied to obtain in-phase and out-of-phase images. Qualitative analysis of the MR images was done by three experienced observers, who reported their confidence in diagnosing the benignity versus the malignancy of the adrenal masses on the basis of signal loss on out-of-phase images. Quantitative analysis was performed by calculating the difference in signal intensity between in-phase and out-of-phase images by use of regions of interest (signal intensity index) and by use of adrenal-liver, adrenal-spleen, and adrenal-muscle signal intensity ratios. Results between quantitative and qualitative measures were compared by use of receiver operating characteristic (ROC) analysis.The mean signal intensity was significantly different between adenomas and metastases on out-of-phase images (64 versus 98) (p.0005) but not in-phase images (130 versus 122) (p = .47). The adrenal-spleen ratio discriminated between adenomas and metastases better than did the adrenal-liver ratio, the adrenal-muscle ratio, or the signal intensity index. No significant difference in interpretation among the three observers was evident (areas under the ROC curves, 0.93, 0.95, and 0.96). The performance of the observers was comparable to the results obtained with the adrenal-spleen ratio measurement (area under the ROC curve, 0.97).Experienced observers were able to differentiate adrenal adenomas from metastases just as well as quantitative measures. The adrenal-spleen ratio is the best quantitative means of distinguishing benign from malignant adrenal masses. Chemical shift MR imaging is a good but imperfect discriminator of adrenal adenomas.

Dr. McFarland. A 68-year-old woman was admitted to the gynecologic oncology service because of increasing abdominal girth, nausea, and abdominal pain. Eight months ago she had undergone an abdominal hysterectomy and bilateral saipingo-oophorectomy, pelvic lymph node dissection, and omental biopsy and had been found to have grade Il-Ill, stage lB papillary serous adenocarcinoma of the endometrium. She had received no adjuvant chemotherapy. On admission, she had ascites shown by clinical examination and CT, along with diffuse omental disease (Fig. 1A). Serum albumin level was low, at 2.4 g/dI (normal range, 3.14.3 g/dI). The level of carcinoembryonic antigen was elevated, at 432 .tg/mI (reference range, 0-35 ig/ml). Sonographically guided abdominal paracentesis yielded 3.5 I of fluid. Adenocarcinoma was detected on cytologic examination of this fluid. These findings were all consistent with recurrent endometrial carcinoma. Adjuvant chemotherapy was started. A nasogastric tube was passed due to recurrent emesis of approximately 200-400 mI/day. A week later, the patient remained nauseated with nasogastric output approximating 400 mI/day. Her abdominal girth had again increased and a further 5 I of ascitic fluid was removed under sonographic guidance. The serum albumin level had dropped to 1 .8 g/dI. A Hickman catheter was inserted surgically 2 weeks after admission, after which total parenteral nutrition was begun. Two days later, her abdominal girth had again increased and she continued to complain of nausea and retching. Nasogastric output continued at 250-400 mI/day. An upper gastrointestinal series and follow-through showed severe gastroesophageal reflux, but further evaluation of the small bowel was not possible as the patient could not tolerate further barium, despite injection through the nasogastric tube. It was decided that a percutaneous gastrojejunostomy should be done for long-term drainage of the small bowel.

Patients in the intensive care unit are at increased risk of developing acute calculous and acalculous cholecystitis. Diagnosis based on clinical and sonographic findings is difficult in the presence of severe intercurrent disease. We did a study to evaluate the efficacy of percutaneous cholecystostomy as a diagnostic and therapeutic maneuver in 82 patients in the intensive care unit who had persistent unexplained sepsis.Eighty-two patients with unexplained sepsis underwent percutaneous cholecystostomy after a complete clinical, laboratory, and radiologic search showed no source of sepsis outside the gallbladder. All patients were febrile, 65 had an increased WBC count, and 37 were receiving vasopressors. Sonographic abnormalities included a distended gallbladder (71 patients), sludge (63 patients), gallstones (26 patients), wall thickening (34 patients), pericholecystic fluid (25 patients), and Murphy's sign (19 patients).Sonographic findings were not helpful in predicting response to percutaneous cholecystostomy. A dramatic improvement in clinical condition was observed in 48 patients (59%) within 48 hr. Signs of improvement included defervescence (41 patients), discontinuance of vasopressors (26 patients), and reduction in WBC count (33 patients). No clinical response was observed in 34 patients (41%). No complications related to catheter insertion occurred.Because acute cholecystitis is difficult to diagnose in patients in the intensive care unit, percutaneous cholecystostomy serves as a diagnostic and therapeutic maneuver in patients with unexplained sepsis when the gallbladder is the suspected source of sepsis. A response rate to percutaneous cholecystostomy of 59% was seen in this study. The gallbladder was cleared as a potential source of sepsis in the remaining patients.

Tracking of interventional radiology procedures is essential for patients' care, follow-up, and quality management, as well as for fellowship training and accreditation. Computer data-base systems that require time-consuming data entry are difficult to use in a practice that performs 1500 abdominal interventional procedures each year while concurrently doing diagnostic imaging. We proposed that a data base updated with data from existing sources and furnishing information used daily in patient management could be maintained by the radiologists it serves.We developed a data base to track abdominal interventional radiology cases by using the HyperCard application program running on Macintosh personal computers. For each procedure, one card is entered into the Current Cases stack, which prints a daily log including new patients, those with management issues, and pending biopsy results. Cards for inactive patients are automatically compressed and transferred to a second stack for permanent archive. The latter can be queried to identify individual patients, to list complications, and for research.In continuous use for 3 years, the system has logged 4322 procedures in 2394 patients. Ninety percent of data entry is by a secretary. The daily log serves as the focus for the case conference at the close of work, when errors are corrected and specific comments entered. Three independent searches for specific types of procedures have failed to identify excluded cases.Easy data entry and error correction, together with useful information provided daily by the data base, are features of the system that promote its consistent use.

Dr. Eisenberg. A 61 -year-old woman was admitted for elective resection of a 6.2 x 7.2 cm thoracoabdominal aortic aneurysm. A leftrenal artery bypass was performed, and a splenectomy was undertaken because of intraoperative hemorrhage. Low-grade fevers were noted postoperatively. Ten days later, treatment with IV vancomycin and metronidazole was started because of the patient’s fever (1 02#{176}F). The next day, an abdominal CT scan showed a left-sided subphnenic collection that contained extravasated oral contrast medium (Fig. 1A). This patient had an abscess with a fistulous communication to the stomach that was shown by CT. Why not proceed directly to surgery to drain the abscess and close the fistula? Dr. Mueller. This is certainly a good option for this type of problem in that both the abscess and the fistula can be dealt with at the same time. However, this patient had some complicating factors. The surgeons elected not to operate because the patient was still recovering from hen original operation, and they did not want to perform any surgery near the patient’s graft. The left-sided subphrenic collection was drained pencutaneously by using the Seldinger technique and a combination of sonognaphic and fluoroscopic guidance (Fig. 1 B). At sonography, the collection was localized, and a position below the costal margin was marked to avoid the pleural space. Under sonographic guidance, an 18-gauge sheath needle was angled up into the left subphrenic space, and cloudy, yellow fluid was aspirated and sent for culture. The aspirate later grew mixed flora including Serratia marcescens, Torulopsis glabrata, Candida, and enterococci. A 0.038-in. guidewine (Lundenquist, Cook, Bloomington, IN) was coiled into the abscess under fluonoscopic guidance, and the track was dilated with 8-, 10-, 12-, and 14-French fascial dilatons. A 12French sump catheter was then inserted over the guidewine into the left subphnenic space. A spot film of the abscess showed a large perforation along the greater curvature of the stomach (Fig. 1C). Dr. Eisenberg. Great efforts were made to avoid traversing the pleural space in draining the abscess in this patient. Is this something that you always do? Dr. Lee. Intuitively, and following standard surgical pnmncipie, it makes sense to avoid traversing the pleura when draining subphnenic abscesses. In most cases, this involves angling up from below the pleural attachments at the 12th rib posteriorly, 10th rib laterally, and eighth rib anteriorly. In this patient, an approach that avoided the pleural space was relatively easy because the spleen had been removed. However, if the spleen is present, it may be difficult to use a subcostal approach without going through the spleen. Consequently, one may have to make a choice of either traversing the pleural space, traversing the spleen, on not draining the collection. Obviously, traversing the spleen is dangerous because of the potential for bleeding. Not draining the collection is an option, but this would mandate surgical intervention. In selected cases, we have begun to use an intercostal tnanspleunal approach. The safety of tnanspleural drainage is partly based on reports in surgical publications that have noted that a direct transpleunal route can be safely used because, by the time a subphnenic abscess has been diagnosed, the adjacent pleural surfaces are firmly adherent to

Percutaneous biliary stricture dilatation (PBSD) is an uncomfortable procedure for patients that presently requires multiple dilatation sessions spread over many days. We evaluated the use of general anesthesia to enable PBSD to be performed in a single sitting in 14 patients with benign biliary strictures (11 anastomotic and three iatrogenic strictures). Four patients had multiple strictures, and the other 10 had a single stricture. Strictures were documented by transhepatic cholangiography (11 patients) or T-tube cholangiography (three); quantitative biliary perfusion studies were additionally performed in seven cases. Dilatation was performed transhepatically in 11 patients and via a T-tube track in three. Balloons ranged from 8 to 12 mm in diameter and were manually inflated for 3 min with an average of five inflations per stricture. Stenting catheters were left across the strictured areas in all patients for 6-21 days (mean, 10 days) before removal. The mean duration of hospital stay for all patients was 5.7 days, which could further be divided into means of 3.6 days (range, 1-6 days) for 11 patients without complications and 13.7 days (range, 13-14 days) for three patients who had complications. Complications included cholangitis; liver hematoma (which resolved with conservative therapy in both cases); and pseudoaneurysm of the hepatic artery, which necessitated angiographic embolization. PBSD achieved long-term patency in 13 (93%) of 14 patients with a follow-up period of 2.0 to 5.5 years (mean, 3.2 years). A stricture recurred in one patient 1.5 years after dilatation. We conclude that PBSD with the patient under general anesthesia can be performed in a single visit to the radiology department with excellent long-term patency rates, a shorter hospital stay, and a pain-free procedure for the patient.

Because of the difficulty in diagnosing acute cholecystitis in critically ill patients with severe intercurrent illness by clinical and imaging methods or percutaneous aspiration of the gallbladder, a trial of percutaneous cholecystostomy was performed in 24 patients in the intensive-care unit with persistent, unexplained sepsis after a complete clinical, laboratory, and radiologic search showed no alternative source of infection. Persistent high fevers, despite antibiotic therapy, were present in all patients, with elevated WBC count in 18 patients, vague abdominal tenderness in 11, and septic shock requiring vasopressors in 15. Sonographically, all patients had distended, spherical gallbladders, six had gallstones, eight had wall thickening, three had pericholecystic fluid, and four had Murphy's sign. All patients were seen by a senior abdominal surgeon, who agreed to a trial of percutaneous cholecystostomy. Fourteen patients (58%) responded to percutaneous cholecystostomy, as evidenced by a decrease in WBC count, defervescence, and the ability to be weaned off vasopressors. Bile cultures were positive in four patients. Ten patients (42%) did not respond to percutaneous cholecystostomy; five eventually died of unrelated causes. A respiratory source of infection was eventually found in three of these 10 patients, with no proved source of infection in the remainder. No complications related to catheter insertion occurred in this group of patients. Bile leaks occurred in two patients when the percutaneous cholecystostomy catheter was removed, but without serious consequence. Our experience suggests that a lower threshold for performing percutaneous cholecystostomy in this difficult clinical subset of patients is worthwhile.

We report our experience with radiologically guided percutaneous tube gastrostomy in 125 patients by using a gastropexy technique in which the anterior gastric wall is nonsurgically sutured to the anterior abdominal wall with percutaneously placed T-fasteners before catheter insertion. Short-term follow-up of up to 2 weeks was available in all patients. In 63 patients, long-term follow-up (greater than 4 weeks; average, 3.5 months; maximum, 1 year) was available. Catheter placement was successful in 124 (99%) of 125 patients, including three patients with anatomic changes after Bilroth II hemigastrectomy and two patients with failed endoscopic attempts. There were no deaths related to the procedure, and no patients required surgical intervention for complications attributable to the gastrostomy procedure. The 30-day mortality rate was 11% (n = 7). These deaths were due to cardiorespiratory arrest and were not attributable to the gastrostomy procedure. Major complications occurred in 1.6% (n = 1) and minor complications in 9.5% (n = 6). These results indicate that percutaneous gastrostomy with gastropexy is a safe and effective technique for placement of catheters in the stomach.

We used a pulsed tunable dye laser (operating at 60 mJ per pulse, 504-nm wavelength) to fragment large (0.8-4.5 cm) stones retained in the hepatic ducts or common bile duct in 12 patients after cholecystectomy. Attempts to extract stones via a T-tube or endoscope had been unsuccessful in all patients. In nine of 12 patients, all stone fragments were successfully eliminated during the initial treatment. In one patient, fragmentation occurred but debris remained, requiring endoscopic stenting. Pseudomonas sepsis developed in this patient 30 days after the procedure and was treated by extraction of the stone fragments. Fragments remaining after lithotripsy were cleared at the same sitting by using saline flushing or endoscopic or percutaneous basket extraction. In two of 12 patients, the treatment was unsuccessful because of laser malfunction. The treatment was performed without complications, except for clinically insignificant hyperamylasemia, which occurred in two patients. Our experience suggests that laser lithotripsy offers a safe alternative for nonsurgical treatment of large retained biliary stones for patients in whom traditional treatments have failed.

Pleural sclerosis after drainage with a small-bore catheter was performed in 21 patients with malignant pleural effusions. Intrapleural catheters 7- to 24-French in size were placed by using sonographic guidance. Tetracycline (18 patients) and bleomycin (four patients) were used as sclerosing agents (one patient had both). Clinical and radiologic follow-up was available on all patients until they died (range, 2 weeks to 25 months; mean, 3.6 months). Pleural sclerosis was successful in 15 (71%) of 21 patients. Two patients in whom pleurodesis failed had pleural sclerosis repeated, with one success and one failure. All of the failures were in patients in whom the amount of chest-tube drainage was more than 100 ml/day. Pleurodesis with tetracycline was painful in six patients; no pain was associated with use of bleomycin. Small pneumothoraces developed in four patients at the time of chest-tube placement, without consequence. A superimposed infection that developed in a patient having continuous drainage of pleural fluid was successfully treated with antibiotics. Pleural sclerotherapy can be performed through sonographically placed small-bore catheters with results comparable to those seen with large-bore, surgically placed catheters.