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Two patients with annular pancreas are described. The diagnosis was established unequivocally with endoscopic retrograde cholangiopancreatography before operation. In both patients there was pancreatitis of the annular pancreas. The first patient also had congenital absence of the ventral pancreas and pancreatic insufficiency. The second patient subsequently developed gastric outlet obstruction. The literature is reviewed.

Arteriohepatic dysplasia is a congenital syndrome associated with life-long cholestasis. Because of symptoms suggesting extrahepatic biliary tract obstruction, we studied three patients with this syndrome by endoscopic retrograde cholangiopancreatogram (ERCP). All patients showed a decrease in the number of intrahepatic ducts. In addition, the intrahepatic ducts show attenuation with focal areas of dilatation. In one subject, this latter finding appeared to be a localized process. The extrahepatic ducts were also narrowed. One patient in this series was found to have gallstones and another cirrhosis. Although the relationship of these anomalies to the cholestasis seen in these patients is unclear, arteriohepatic dysplasis can be added to the list of processes associated with biliary tract abnormalities.

A collection of barium simulating an ulcer, or a negative defect simulating a mass, frequently occurs at the junction of the first and second portions of the duodenum. This appearance may be related to several factors, including (a) distortion produced by flexion, (b) sphincter function, and (c) an extrinsic impression. Several such patients have had negative findings on endoscopy. The defect can be distinguished from a true lesion by its characteristic location and its variable appearance on different projections.

Fifty-one patients were admitted to a single practice at St. Joseph's Hospital between April 1, 1978, and April 1, 1986 with a diagnosis of squamous cell carcinoma of the vulva greater than 1 mm in depth. Five advanced lesions were treated with combinations of radiation and surgery. Four patients had recurrent squamous cell carcinoma. Of 42 patients treated surgically with intention of cure, 14 were treated with complete radical vulvectomy and bilateral inguinofemoral lymphadenectomies, and 28 patients were treated with complete radical vulvectomy and bilateral inguinofemoral lymphadenectomies, and 28 patients were treated in 26 instances with bilateral inguinofemoral lymphadenectomies in one of five different excision patterns individualized to the site of primary tumor. None of the 28 patients have had a recurrence. Five had positive nodes. Eight have died of unrelated causes. Lesions in 25 cases were stage I or II and in three cases they were stage III. Modified radical vulvectomy and bilateral groin dissection is a safe approach for most patients with stage I or II and occasionally even stage III lesions.

A patient underwent a routine percutaneous liver biopsy and subsequently developed gastrointestinal hemorrhage, biliary colic, and bilirubinuria suggesting the presence of hemobilia. After a negative arteriogram endoscopic cholangiography was used to confirm the diagnosis.

In potato line Mb1501B one or possibly two normal size Ti TL-DNA copies per tetraploid genome were detected by Southern blot analysis, but no TR-DNA. The TL-DNA probably contained the entire transposon Tn1831 inserted at the T-DNA auxin gene for transcript 2. Northern blot analyses of the steady-state RNA in different Mb1501B tissues isolated from (i) shoots cultured in vitro (ii) grafted plants and (iii) tubers, showed that that TL-DNA transcripts 3, 4, 6a and 7 were expressed most abundantly in the cultured shoots. They formed approximately 0.0023 to 0.0007% of the total poly(A) RNA. Transcripts 1, 5 and 6b were not detected in any of the tissues analysed. This indicated even lower levels of expression (below approximately 0.0001% of the total poly(A) RNA or, making certain assumptions, an abundance of less than one T-DNA derived RNA molecule per cell). As expected, transcript 2 was not detected in any of the Mb1501B tissues. The abundance of the transcripts was reduced in grafted plants and tubers compared with cultured shoots with the greatest decrease (5×) for transcripts 4, 6a and 7. Transcript 4, the one most responsible for the changed growth and development of Mb 1501 B, formed approximately 0.0003% of the poly(A) RNA from both grafted plants and tubers.

In a retrospective study, 1,416 cholecystectomies performed during a three-year period were reviewed to define the risk of cholecystectomy when combined with another intra-abdominal procedure. Group 1, cholecystectomy alone (1,148 patients), with subsets of cholangiography and/or common bile duct exploration, had a complication rate of 14.29% and a mortality of 0.52%. Group 2, primary cholecystectomy combined with secondary intra-abdominal surgery (214 patients), had a complication rate of 19.63%. Group 3, primary intra-abdominal surgical procedure with incidental cholecystectomy (54 patients), had a complication rate of 20.37%. Mortality for groups 2 and 3 was 2.24%. The rate of nonfatal complications was increased slightly when a second surgical procedure was performed (14.29% v 19.78%). Pairing cholecystectomy with other intra-abdominal surgery is advised only when surgical exposure is adequate, the patient's condition is satisfactory, and operating time is not prolonged greatly.

We review the discrepancies and the reasons for them, in two articles in this issue of the Journal to conclude that clinical findings hold the key to selection of the proper imaging test in biliary obstruction. Cholescintigraphy is a more rewarding approach in detecting low grade obstruction, as by common duct stones, whereas in the patient with prolonged painless jaundice, and the high likelihood of a malignancy, computed tomography or ultrasound will yield the best results. Because of the potential for noninvasive imaging to miss choledocholithiasis and because of ever increasing therapeutic options, direct cholangiography will continue to be the mainstay in definition evaluation of the biliary tract.

An unusual sign of malignancy in the colon is described, consisting of an intraluminal lenticular ulcer surrounded by a meniscoid lucency of tumor. This constellation of findings was first described by Carman as a specific indicator of gastric malignancy. An aggressive ulcerating lesion with these characteristics, while rare in the colon, raises the suspicion of carcinoma.

The development of colon carcinoma after ureterosigmoidostomy has not received adequate attention in the radiologic literature. Two patients who had ureterosigmoidostomy and subsequently developed tumors are described. The third case is a patient with a ureterosigmoidostomy and a ureterocele that simulated the appearance of carcinoma in the sigmoid colon. This is the first report of this entity. Ureterosigmoidostomy patients need frequent follow-up studies since their incidence of carcinoma is significant. The use of barium to study the colon in this group of patients is controversial. Barium can potentially reflux into the kidney with fecal material, which can lead to fibrosis and impaired renal function. However, barium reflux up the ureter is usually of no significance except on those rare occasions when intrarenal reflux occurs and inflammatory changes may develop. The diagnosis of tumors in these patients, diagnostic pitfalls, and controversy regarding use of barium enemas in following these patients are discussed.

When faced with a patient with possible acute cholecystitis, technetium-99m-HIDA scintigraphy should be the primary diagnostic procedure performed. If scintigraphy reveals a normal gallbladder, acute cholecystitis is excluded. If the scintigram fails to visualize the gallbladder, ultrasonography is deemed advisable to exclude potential false-positive scintigrams and confirm the presence of cholelithiasis.

It is difficult to truly define iatrogenic complications in the postsurgical state in that the surgery is a condition originated by physician intervention and thus any problems that occur may be technically considered as physician created. In this article we attempt to demonstrate problems that occur both due to technical errors and the choice of operative procedure. In addition, unusual postsurgical anatomy is illustrated with the hope of avoiding further iatrogenic problems from lack of recognition.

Oral doses of either iopronic acid (4.5 g Oravue, Squibb) or iopanoic acid (3 g Telepaque, Winthrop) were given to 98 patients requiring cholecystography. Radiographs were taken 13 to 16 hours after treatment showed good to excellent gallbladder opacification in 44 percent of patients after the first dose of iopronic acid and in an additional 29 percent after a second dose. Similar opacification occurred in 42 percent of patients after the first dose of iopanoic acid and in 34 percent after a second dose. Drug-related abnormalities in blood and urine tests occurred about equally in both groups and one patient in each group exhibited a clinically adverse reaction (diarrhea). Thus, the performance (radiographic efficacy and drug safety) of the new contrast agent, iopronic acid, was similar to a widely used drug, iopanoic acid.

Transient hypertrophic gastropathy in a child with similarity of radiographic and clinical features to Menetrier's disease is described. Distinction from Menetrier's disease is emphasized as the condition is characterized by abrupt onset, short duration, eosinophila and good prognosis. The association with hypersensitivity as a possible etiology is more suggestive in this condition. The radiographic changes will often provide the first clue to this condition and rapid reversal of the gastric changes is diagnostic.

Thirteen consecutive cases of vulvar Paget's disease treated by us between 1975 and 1984 underwent pathologic retrospective review. In the first group of eight patients having Paget's disease not involving the anal mucosa, the extent of disease was completely defined by frozen-section margins. Additional intraoperative resections were necessary in five of the eight. None had residual involvement on permanent sections and none had recurrences in 3 to 8 years of follow-up, although two died of unrelated causes. A second group of two patients early in the series had frozen sections to define some but not all of the margins. Both had positive perineal margins on permanent sections. One has required two subsequent revisions after 3 years of follow-up and the other has been free of disease during 9 years of follow-up. A third group of three patients all had anal mucosal involvement and all had associated mucinous adenocarcinoma of the rectum. Frozen sections actually discovered the presence of one of the three carcinomas. After appropriate radical operations, all three are alive and free of disease between 2 and 9 years of follow-up. It is concluded: patients with vulvar Paget's disease can reduce the need for subsequent operations with the use of frozen sections to define surgical margins; anal mucosal involvement of Paget's disease represents an ominous sign of underlying carcinoma.

Eight cases of wandering spleen demonstrate that this rare entity has a characteristic constellation of findings which, though nonspecific, are highly suggestive of the diagnosis. Angiography or isotopic imaging specific for the spleen confirms the diagnosis. Asymptomatic patients may be carefully observed, with the institution of splenectomy should signs of torsion develop.

Aperistalsis of the esophagus was demonstrated in six patients with esophagitis. This was observed in reflux, caustic, and infectious esophagitis, and has occurred both as a transient phenomenon with no further sequelae, and as the initial manifestation of involvement in patients who subsequently suffered stricture. Based on biopsy and autopsy specimens in two cases, a possible mechanism of aperistalsis related to the damage to neurons in Auerbach's plexus is postulated. The presence of aperistalsis has been the first significant clue to esophageal inflammation in several cases.

We evaluated the radiologic studies of 23 patients with surgically or autopsy-documented gallbladder perforation. Extravasation was shown by cholescintigraphy and cholangiography in seven patients and corresponded to free perforation or large pericholecystic loculation. In 16 patients, ultrasonography and computed tomography detected fluid and abscesses outside the gallbladder ranging from 1 to 2 mm pericholecystic fluid collections to large phlegmonous masses. A right, upper-quadrant mass on plain films and scattered calcification in this area suggested perforation. Gallbladder perforation could be diagnosed or suspected preoperatively in ten patients and antemortem in 22 of 23 individuals. This rate of recognition, higher than previously reported, may be ascribed in part to improvements in biliary imaging.

Thorotrast granuloma of the neck is an extensive benign connective tissue overgrowth secondary to localized extravasation of contrast. This can present with dysphagia secondary to mass effect or motor disorder of swallowing related to demyelinization of the ninth through twelfth cranial nerves. The radiographic appearance is characteristic in both location and density.

A review of 97 patients with adult hepatorenal polycystic disease (AHRPD) revealed a significant number of patients with gastrointestinal symptoms as the initial or primary manifestation of their disease. The typical appearance of the gastrointestinal barium examinations is presented.

The gastrointestinal tract is a common target for adverse drug reactions. The resultant changes are often nonspecific (e.g., mucosal ulceration, intestinal infarction, motility disturbance) and in many cases no radiographically detectable lesion may occur. A comprehensive review of the reported drug-induced disorders of the digestive organs is herein presented and their radiographic manifestations are described.

Gastric surgery has undergone continuous evolution since the 19th century. At present it is a highly sophisticated technique which provides symptomatic relief for the vast majority of patients operated upon for peptic ulcer disease. Although the overall incidence of complications has decreased, a variety of complications continues to occur and radiological examination plays a critical role in their detection, evaluation, and management. Knowledge of the variations in surgical terminology and commonly used eponyms provides the basic framework for discussion. Familiarity with the radiological appearance of the normal postoperative stomach together with an understanding of its physiology are essential prerequisites to the recognition of possible complications. Operative techniques may result in a radiographic appearance which simulates disease. Conditions as diverse as bezoars, afferent and efferent loop problems, marginal ulceration, anastomotic leakage, prolapse, and intussuception may all be characterized by distinct and highly specific radiographic changes. Physiologic problems such as dumping and malabsorption may also reflect their presence by X-ray changes. The radiographic features in a large number of surgical complications are discussed and illustrated. The importance of the radiographic examination in the postsurgical stomach is emphasized.