Evaluating suspected small bowel obstruction with the water-soluble contrast challenge

With optimized technique, the water-soluble contrast (WSC) challenge is effective at triaging patients for operative versus non-operative management of suspected small bowel obstruction (SBO). Standardized study structure and interpretation guidelines aid in clinical efficacy and ease of use. Many tips and tricks exist regarding technique and interpretation, and their understanding may assist the interpreting radiologist. In the future, a CT-based WSC challenge, utilizing oral contrast given as part of the initial CT examination, might allow for a more streamlined algorithm and provide more rapid results.

Diagnosis of Anastomotic Leak

Anastomotic leaks after colorectal surgery is associated with increased morbidity and mortality. Understanding the impact of anastomotic leaks and their risk factors can help the surgeon avoid any modifiable pitfalls. The diagnosis of an anastomotic leak can be elusive but can be discerned by the patient's global clinical assessment, adjunctive laboratory data and radiological assessment. The use of inflammatory markers such as C-Reactive Protein and Procalcitonin have recently gained traction as harbingers for a leak. A CT scan and/or a water soluble contrast study can further elucidate the location and severity of a leak. Further intervention is then individualized on the spectrum of simple observation with resolution or surgical intervention.

1457 Subcutaneous Emphysema in Adolescents: A Trap for The Unwary

A 16-year-old, Caucasian girl presented with sudden-onset pleuritic chest pain (CP), vomiting and shortness of breath. Nil past medical history; nil medications; nil trauma/ surgery. She was tachycardic, tachypnoeic and apyrexial with oxygen saturations >96% on air. There was significant right-sided facial and neck swelling. Chest palpation demonstrated crepitations suggesting subcutaneous emphysema (SE). Urinalysis was negative. Laboratory tests revealed leucocytosis and neutrophilia. Chest X-Ray: SE. CT Thorax: extensive gas within mediastinal cavity tracking along great vessels and within subcutaneous tissues with left, apical pneumothorax. Two air-filled tracts communicating between oesophagus and mediastinal cavity, ∼2cm from gastro-oesophageal junction, indicated oesophageal rupture. Conservative management included IV Fluids, antibiotics and feeding via total parenteral nutrition. After 1-week, oral water-soluble-contrast was administered. Subsequent imaging showed no evidence of extra-luminal extravasation and she was discharged. At 4-week follow-up, normal dietary intake was re-established with no complications. Discussion Boerhaave’s syndrome (BS) (described by Dutch physician Herman Boerhaave in 1724) is the phenomenon of spontaneous oesophageal perforation. The underlying mechanism is due to a sudden rise in intra-luminal pressure against a closed glottis resulting in barotrauma. BS in adolescents remains a rare entity with a paucity of reported cases. Mackler’s triad describes the classical presentation comprising vomiting, CP and SE. Non-specific presentation may delay diagnosis and a high clinical index of suspicion is required. CT thorax and water-soluble-contrast studies are diagnostic. Timing of presentation, complications and haemodynamic status dictate conservative or surgical management approach. BS carries a 20-40% mortality, and must be included in differential diagnoses of adolescents presenting with vomiting and CP.

Case report of a 72-year-old man with diaphragmatic hernia and thoracic gastropericardial fistula after esophagectomy for 18 years

Background Both diaphragmatic hernia and thoracic gastropericardial fistula rarely occur simultaneously in patients with radical esophagectomy. Case presentation A 72-year-old man presented to our hospital with 1 day of nausea, vomiting and acute left chest pain. He had radical esophagectomy (Sweet approach) for esophageal cancer 18 years ago. Computed tomography (CT) of the chest revealed diaphragmatic hernias and air collection within the pericardial space. While an operation of diaphragmatic hernia repair was decisively performed to prevent further serious complications, unusually, a thoracic gastropericardial fistula was also found unusually. Conclusion Diaphragmatic hernia and thoracic gastropericardial fistula may occasionally coexist in patients with esophagectomy. Upper GI radiograph with a water-soluble contrast agent is a better diagnostic tool than CT in visualizing the fistula.

Case report of A 72-year-old Man with Diaphragmatic Hernias and Thoracic Gastropericardial Fistula after Esophagectomy for 18 Years

Background: Both diaphragmatic hernias and thoracic gastropericardial fistula rarely occurred simultaneously on patients with radical esophagectomy.Case presentation: A 72-year-old man presented to our hospital with one day of nausea, vomiting and acute left chest pain. He had radical esophagectomy for esophageal cancer 18 years ago. Computed tomography (CT) of the chest revealed diaphragmatic hernias and air collection within pericardial space. While an operation of diaphragmatic hernia repair was decisively performed to prevent further serious complications, the thoracic gastropericardial fistula was also found unusually. Conclusion: Diaphragmatic hernias and thoracic gastropericardial fistula may occasionally coexist in patients with esophagectomy. Upper GI radiograph with water-soluble contrast agent is a better diagnosis tool than CT in visualizing the fistula.

Colonic Pseudo-obstruction as a Rare Complication of Pheochromocytoma

Colonic pseudo-obstruction is characterized by dilatation of the colon without a structural lesion causing the obstruction. It usually involves the caecum and right side of the colon and is commonly observed in patients with severe illness or after surgery; it is rarely caused by pheochromocytoma. The diagnosis of colonic pseudo-obstruction can be established by abdominal imaging including computed tomography (CT) of the abdomen or use of a water-soluble contrast enema. In additional to conservative or surgical treatment, alpha-blockers can be used in this setting to relieve the pseudo-obstruction.

Evaluation of the Role of Water-Soluble Contrast Administration in Management of Patients with Adhesive Intestinal Obstruction

Background: Adhesive intestinal obstruction is a common post-operative cause of hospitalization. This study aims to evaluate the oral administration of water-soluble contrast on the outcome of patients with adhesive intestinal obstruction in regard to recovery, operative rate and hospital stay.Methods: In this prospective randomized trial, patients were randomized into two groups: gastrografin (GG) and traditional treatment group (TT). in the gastrografin group (GG)after stomach was emptied through a nasogastric tube, the water soluble contrast follow-through was performed within 24 h of hospital admission using 100 mL of 76% gastrografin injected through the nasogastric tube and erect ,supine abdominal x-ray was taken(at 8,12,24h)later. The endpoints of the study were to evaluate the time interval between admission and relief of obstruction, the length of hospital stay and the need for surgery. Results: Fifty-four patients with a mean age 45 ±2.4years, 25(46.3%) males and 29(53.7%) females. The number of patients who were successfully conservatively treated in the gastrografin group was 22(81.5%), which was significantly higher than 13(48.1%) in the traditional group. among these patients, mean hospital stay in gastrograffin group was 31.3±4.5 hours, which was significant shorter than 48.9±8.2hours in traditional group(p=0.004). Conclusions: Administration of an oral water-soluble contrast agent in postoperative adhesive bowel obstruction helps in the earlier resolution of the obstruction, decreases the length of hospital stay and the need for surgery.