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199
Letters .
.
Hypersensitivity In a recent
occurred
Reaction issue
of AJR,
During
Feczko
during a single-contrast
Barium
a death
that
barium enema. Allergic or anaphy-
lactic reactions to barium sulfate suspensions, although known for some time, are rare, and we feel justified in reporting an additional case of severe hypersensitivity reaction associated with barium enema. The patient was a 43-year-old woman who had had gastric partition for morbid obesity, cholecystectomy, and ventral hernia repair 7 years before.
Her
surgery
had been complicated
by subphrenic
I
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.
‘
:
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:.
#{149}#{149}
:
.“.
‘1
:
‘
. .
REFERENCES
Enema
et al. [1] reported
.
abscess
PJ, Simms SM, Bakirci N. Fatal hypersensitivity
1 . Feczko barium
enema.
reaction during a
AJR 1989;1 53:275-276
2. Schwarz EE, Glick SN, Foggs MB, Silverstein GS. Hypersensitivity tions
after barium
enema
examination.
reac-
AJR 1984;143:
103-1 04 3. Gelfand DW, Sowers JC, DePonte KA, Sumner TE, Ott DJ. Anaphylactic and allergic reactions during double-contrast studies: is glucagon or barium suspension the allergen? AJA 1985;144:405-406
Reply
and multiple viscerocutaneous fistulas. She had a history of allergic reaction (urticaria?) to IV contrast material, but she had not had any side effects associated with earlier barium studies. She had a single-contrast barium enema in May 1988 for preoperative evaluation for a fistula repair. Immediately after completion of the study, the patient began having dyspnea and diffuse wheezing over both lungs, and extensive urticaria developed over her entire body. Her blood pressure was 1 1 0/82 mm Hg, and her respiratory rate was 30/mm. Her respiration improved slowly after she was given 50 mg of Benadryl (diphenhydramine hydrochloride) intramuscularly and oxygen. The itching and urticaria became progressively worse, and 1 00 mg of hydrocortisone was administered intramuscularly. Later, the patient had a limited upper gastrointestinal study with a nonionic contrast material after she was premedicated with prednisone. She experienced no side effects from that study. Most patients who have side effects from a barium enema have a history of allergy. It has been suggested that methylparaben, a preservative [2], or glucagon [3] may be responsible for allergic reactions that occur during barium enemas. In our case, the singlecontrast barium enema was performed without glucagon, and meth-
I thank Brenner et al. for their interest in my article [1 ] and for their report of a hypersensitivity reaction associated with a barium enema. Over the last several months, I have become aware of other serious allergic reactions that have occurred during diagnostic barium studies. Although these events are unusual, radiologists must be made aware of the possibility that such events may occur. At my institution, we currently have both epinephrine and Benadryl (diphenhydramine hydrochloride) available in all fluoroscopic suites because of these reactions. Brenner et al. make several good points. I also think that manufacturers should list all ingredients on the package, but the Food and Drug Administration does not require them to do so. Another fascinating point is that E-Z-EM, Inc., now has a warning about the possibility of allergic reactions to its products on its latest package inserts. This information appears to be a relatively recent addition to the package inserts and is printed in boldface type. Peter J. Feczko Henry Ford Hospital
ylparaben
REFERENCE
is not listed specifically
as one of the ingredients
in the
preparation(E-Z-EM Disposable Bariuma Enema, E-Z-EM, Inc., Westbury, NY) that we used. However, in cases reported in the literature, barium suspensions from the same company were used, and one of the patients had a positive response to methylparaben in hypersensitivity
tests
Detroit,
1 . Feczko barium
PJ, Simms SM, Bakirci N. Fatal hypersensitivity AJR 1989;153:275-276
Ml
48202
reaction during a
enema.
[2].
It would be highly desirable to have all ingredients listed on the package and the possibility of side effects stated in the description of all barium suspensions. Jeffrey
S. Brenner John O’NeiI
Jun V. Kaude University
of Florida,
College
Gainesville,
of Medicine
FL 32610
Low-Attenuation
Mediastinal
Masses
on CT
The pictorial essay by Glazer et al. [1] provides a comprehensive of cystic mediastinal masses. However, I recently have seen a case not mentioned in this differential diagnosis that I believe may be of general interest as an uncommon manifestation of a common disease. An 84-year-old woman had had dyspnea for several weeks, particularly when she was lying down. Screening chest radiography showed review
LETTERS
200
AJR:154,
January 1990
REFERENCE 1 . Glazer HS, Siegel MJ, Sagel 55. Low-attenuation CT.AJR
Tuberculosis Downloaded from www.ajronline.org by 69.11.182.82 on 10/19/15 from IP address 69.11.182.82. Copyright ARRS. For personal use only; all rights reserved
mediastinal
masses on
1989;152:1173-1177
and Peptic Stricture
of the Esophagus
We describe an unusual case of tuberculosis complicating peptic stricture of the esophagus. A 45-year-old woman who had been having retrosternal burning for several years presented with dysphagia. A barium esophagogram showed a smooth stricture of the distal 5 cm of the esophagus (Fig. 1). The patient refused any intervention at this time and was treated antacids for peptic-acid disease. Five years later, she presented with worsening dysphagia. A repeat esophagogram showed no significant change in the degree of the stricture; however, multiple ulcerations were seen proximal to the stricture. No definite pathologic diagnosis could be made because the patient refused endoscopic biopsy. Six months later, she returned because of constant, dull, aching retrostemal pain. A barium esophagogram showed a localized with
Fig. 1.-A and B, CT scans show cystic mass in middle mediastinum. Trachea and superior vena cava are compressed (A), and mass extends up to thoracic
inlet on right side (B).
a mediastinal mass. CT scan showed a cystic mass in the middle mediastinum with compression of the trachea and superior vena cava (Fig. 1). The mass extended up to the thoracic inlet on the right. At mediastinal biopsy, the mass was soft but definitely encapsulated. The cystic part consisted of necrotic debris. Examination of biopsy specimens from the capsule showed poorly differentiated lymphocys-
tic lymphoma. Non-Hodgkin lymphoma presents as a purely mediastinal mass in less than 10% ofcases [2]. Primary mediastinal lymphoma presenting as a cystic mass in the mediastinum is a possibility not mentioned in either
the pictorial
essay
[2, 3]. As non-Hodgkin
or the two major textbooks
lymphoma
is a common
on CT scanning
disease,
I think that
probably will not be an isolated case and that non-Hodgkin lymphoma should be included in the differential diagnosis of cystic mediastinal masses. Jack T. English St. Francis Medical Center La Crosse, WI 54601 this
REFERENCES 1 . Glazer
HS, Siegel MJ, Sagel 55. Low-attenuation
CT.AJR
mediastinal
leak
of contrast
material
from
the
region
of the
ulceration
proximal to
the stricture. The patient agreed to have surgery, and a localized periesophageal abscess was excised along with the adjacent cardioesophageal junction. An esophagogastrostomy was performed. The patient’s recovery was uneventful. Histopathologic examination of the resected
specimen showed classic tuberculous granulation tissue in the wall of the esophagus, in relation to the ulcers. Lymph nodes surrounding the abscess also showed tuberculous granulation with caseation. Esophageal involvement in tuberculosis is seen at autopsy in less than 1 % of patients who have this disease [1]. Though such involvement invariably is associated with advanced pulmonary or mediastinal tuberculosis,
isolated
cases
of primary
esophageal
tuberculosis
have
been reported
[2]. In such cases, as in our patient, the diagnosis seldom is suspected preoperatively. Symptoms are often nonspecific and include dysphagia and chest pain [3]. Ulceration in peptic strictures of the esophagus occurs in the strictured segment itself. On the other hand, ulceration and perforation in an area proximal to a peptic stricture strongly suggests a nonpeptic cause of ulceration. The differential diagnosis for such proximal ulceration includes drug-induced esophagitis, herpetic or
masses on
1989;152:1173-1177
2. Sagel 55, Glazer HS. Mediastinum. In: Lee JKT, Sagel 55, Stanley RJ. Computed body tomography, 2nd ed. New York: Raven, 1989:245-294 3. Bick RJ, Haaga JR, Solemon EH. The mediastinum. In: Computed tomography
of the whole
body,
2nd ed. St. Louis: Mosby,
1988:570-648
Reply We thank Dr. English for describing his case of mediastinal nonHodgkin lymphoma. As stated in our article [1], any neoplasm with necrosis may have areas of low attenuation that often is not absolute but relative to the enhancing wall of the lesion or to surrounding structures on IV contrast-enhanced CT scans. Determination of the precise attenuation value in these cases actually discloses a density close to that of soft tissue, which we are certain is the situation in the submitted illustrations. This needs to be distinguished from true cystic
lesions
with
be seen in patients
attenuation
values
who have Hodgkin
near
those
of water
that
may
lymphoma.
Harvey S. Glazer Marilyn Stuart Mallinckrodt
Institute
St. Louis,
J. Siegel S. Sagel
of Radiology
MO 63110
Fig. 1.-Tuberculosis and peptic stricture of the esophagus. A, Initial esophagogram shows peptic stricture. B, Esophagogram obtained 5 years after A shows ulcerations
proximal to stricture. C, Esophagogram and leak of contrast
(arrows)
obtained 6 months after B shows local perforation material
(arrow).
candidial
wish
infection,
to stress
and
Crohn
disease
that in areas
nocompromised
patients,
and perforation
[2].
endemic
tuberculosis
proximal
With
this
case
for tuberculosis
to a peptic
report,
Akiyosi
we
and in immu-
Tokyo
Tokyo
REFERENCES 1 . Lockard LB. Esophageal tuberculosis: a critical review. Laryngoscope 1913;23:561 -584 2. Fahmy AR, Guindi R, Farid A. Tuberculosis of the esophagus. Thorax 1969;24:254-256 3. Rubinstein BN, Patrana T. Jacobson HG. Tuberculosis of the esophagus.
1 . Anthony PP, Telesinghe Pathol 1986;39:761-768
Inflammatory
unknown
[1 -4].
Pseudotumor pseudotumor
infiltration
is rare,
a case in which
and
the cause
the diagnosis
is still
was con-
multiple septa were seen after administration of (Fig. 1 A). Percutaneous needle biopsy of the tumor
examination
of inflammatory
of malignancy.
cells
No diagnosis
of the biopsy
in the
could
fibrous
specimen
tissue
and
showed
no evidence
...
:
.
;:;>
‘
,
‘‘..:“-
Investigation
infection
in girls.
radiographic
pseudotumor
A, Contrast-enhanced CT scan with enhancement of septa. B, Photomicrograph of specimen
of liver.
shows
multlloculated
obtained
at surgery
low-density 22 months
area after A
shows numerous lymphocytes and plasma cells in connective tissue cornposed of collagen fibers and fibroblasts. (H and E) At follow-up
and CT showed also showed a mosaiclike hypoechoic area 7 x 8 cm in diameter. Except for the size, the CT appearance was the same as before. An extended right lobectomy of the liver was performed. At surgery, a large solitary the
mass
22 months
had
increased
later,
both
sonography
in size.
Sonography
The
radiation.
This
protocol
jaundice
pseudotumor
and portal
of
hypertension
in a
Histologic examination cells in the connective and fibroblasts (Fig. 1 B).
of Urinary Tract Infection
Imazato
Yoshinori Eiko
Isobe Ueno
may
is the omission
entails become
of the standard
relatively the
positive results of urine cultures obtained clean-catch
high
procedure
exposure of choice
to
if its
specimens
from bagged specimens
in girls
(especially
in those
or less
than 2 years old) are frequent, and we wonder how many children really had urinary tract infections. Urethral catheterization and suprapubic aspiration of the urine are much more reliable methods for collecting urine specimens for determination of urinary tract infections [2,3]. Second, the authors state that reflux nephropathy develops when infected urine refluxes into the renal collecting system and into a refluxing papilla. This point is controversial, and experimental and clinical data appear to indicate that reflux nephropathy can develop in the absence of infection [4]. Strife
et al. minimize
the significance
of the inability
of nuclear
cystography to detect grade I reflux, stating that knowledge that a patient has grade I reflux rarely results in a change in therapy. On the contrary, although grade I reflux is not an indication for surgical correction, prolonged prophylactic antibiotic therapy uniformly is administered in this situation [5, 6]. Finally, Strife et al. correctly emphasize the importance of detecting renal scarring in patients who have urinary tract infection. However, they neglect a large body of evidence [7, 8] that shows that renal nuclear scanning with cortical agents such as “Tc-glucoheptonate
is more effective
than renal sonography
protocol
who have urinary
in children
performing cortical
in detecting
tract infection
a renal scan to determine
scars.
Our
and reflux includes
the presence
or absence
of
scars.
Morris
J. Schoeneman
C. Richard Goldfarb Fukiat Howard
Ongseng Finestone
Beth Israel Medical Center New York, NY 10003
showed numerous lymphocytes tissue composed of collagen fibers Masayuki
advantage which
results can be validated, and if the grading procedure based on the use of isotopes can be mastered by other groups. We have some concerns about the methods used in this study [1 ] and about some of the authors’ statements on the pathophysiology of reflux nephropathy and the treatment of grade I reflux. First, a definition of urinary tract infection is not provided. False-
mass in the right lobe with adhesion with the diaphragm was present. The lesion had a well-demarcated, irregular margin and was yellowish and white. and plasma
major
cystogram,
Third,
that
of obstructive
child. Pediatr Radiol 1984;14:433-435 3. Maeda M, Sakai V. Koyama W, et al. A case of inflammatory pseudotumor of the liver. Liver 1988;29:546-551 4. Yamauti T, Furui S. Ohtomo K, et al. A case of inflammatory pseudotumor of the liver. Nippon Igaku Hoshasen Gakkai Zasshi 1985;30: 1505-1508
midstream
be made.
1
Fig. 1.-Inflammatory
of the liver. J Clin
We were interested in the report by Strife et al. [1 ] describing changes in their protocol for the imaging evaluation of urinary tract
of the Liver
of the liver
We report
was done. Histologic
pseudotumor
-403
firmed at surgery. A 51-year-old man had had epigastric pain for 1 month. Endoscopy revealed a gastric ulcer, and sonography showed a tumor of the liver. CT showed a low density multiloculated lesion in the right lobe of the liver. Enhanced contrast material
PU. Inflammatory
2. Heneghan HA, Kaplan CG, Prieve CJ, et al. Inflammatory
Imaging
Inflammatory
College
162, Japan
REFERENCES
the liver: a rare cause
1958;70:401
Yamada
Medical
stricture. Ravi Ramakantan King Edward Memorial Hospital Bombay, 400 022, India
Radiology
Women’s
can be a cause of ulceration Priti Shah
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201
LETTERS
AJR:154, January 1990
REFERENCES 1 . Strife JL, Bisset sonography:
GS Ill, Kirks DR. et al. Nuclear cystography findings in girls with urinary tract infection. AJR
and renal 1989;153:
LETTERS
202
115-119 2.
‘Tc-dimercaptosuccinic
Ogra PL, Faden HS. Urinary tract infection
Pediatr 1985;106: 1023-1029 4. Hellerstein S. Recurrent urinary
tract
an update. J
in childhood:
infection
in children.
Pediatr
Infect
Dis 1982:1:271-281
Downloaded from www.ajronline.org by 69.11.182.82 on 10/19/15 from IP address 69.11.182.82. Copyright ARRS. For personal use only; all rights reserved
4. McCurdy
FA, Vemier RL. Unique consequences of kidney infections in infants and children: pathogenesis, early recognition, and prevention of scarring. Am J Nephrol 1981;1 :184-1 97 5. Report of the Intemational Reflux Study Committee. Medical versus surgical treatment of primary vesicoureteral reflux. Pediatrics 1981;67: 392-400 6. Aladjem M, Boichis H, Hertz management of vesicoureteral 1980;65:78-80 7. Stoller
AJR:154, January 1990
ML, Kogan
scanning
agents
considerably
acid.
is able
Renal
to show
scintigraphy
renal
higher dose of radiation.
these cortical
with
scarring,
although
Some institutions,
with
own, may proceed to a third study (excretory urography, renal scintigraphy with cortical scanning agents) in high-risk girls (e.g., less than 2 years old, infection with an unusual organism, failure to respond to appropriate antibiotic therapy). We do not recommend this detailed and aggressive imaging as a routine protocol for all
children who have urinary tract infection and reflux. Janet
M, Herzfeld
U. The conservative reflux: a review of 1 21 children. Pediatrics
BA. Sensitivity
5, Raviv
of “Tc-dimercaptosuccinic
diagnosis of chronic pyelonephritis:
Francis
acid for the
Dis
J. Schlueter
Michael J. Gelfand Diane S. Babcock Bokyung K. Han Children’s Hospital Medical Center Cincinnati, OH 45229-2899
acid (DMSA) Arch
L. Strife
George S. Bisset Ill Donald R. Kirks
clinical and theoretical considerations.
J Urol 1986;135:977-980 8. Verber IG, Strudley MR, Meller ST. “Tc-dimercaptosuccinic scan as first investigation of urinary tract infection.
a
including our
Child
1988:63: 1320-1 325
REFERENCES
Reply We are pleased,
experience infection
would
studies.
and in fact had hoped,
in evaluating stimulate
All patients
Radiology
interest,
[1] of our
of girls with urinary tract
discussion,
and
other
controlled
in our study were referred to the Department
at Children’s
had documented
that the report
a large number
Hospital
Medical
a urinary tract infection.
Center
by pediatricians
The standard
of who
definition
of
“significant” bacteriuria is growth of more than 1 00,000 coIonies/,l of a single organism in urine obtained by the clean-catch method. We agree that it is extremely important to obtain a specimen correctly in children so that they will not be mislabeled as having a urinary tract infection.
investigations
of vesicoureteral reflux, infection, and reflux nephropathy have been done over the past few decades. Although it remains controversial if reflux nephropathy can develop in the absence of infection, most agree that reflux provides a potential route for transporting organisms from the lower urinary tract to the Numerous
kidneys,
with possible
subsequent
renal infection
and scarring.
We
evaluated patients in our study only if they had a documented urinary tract infection. McCurdy and Vernier [2] concluded that “the knowl-
edge accumulated over the past 10 years suggests strongly that UTI associated with vesicoureteral reflux is a major cause of renal scarring and an important
cause
of renal failure
in children.”
The question
whether reflux nephropathy can develop in the absence was not addressed in our study. It is difficult
to diagnose
of nuclear cystography.
grade
I vesicoureteral
The length of prophylactic
reflux
of
of infection on the basis
therapy necessary
in patients with grade 0 and grade I reflux remains controversial. Nuclear cystography accurately detects higher grades of reflux; most clinicians agree that infants and children who have these grades of
1 . Strife JL, Bisset GS Ill, Kirks DR, et al. Nuclear cystography sonography: 115-119
2. McCurdy
findings
in girls
with
urinary
tract
infection.
FA, Vemier RI. Unique consequences
infants and children: pathogenesis, early scarring. Am J Nephrol 1981;1 :184-197 rography: 479-482
findings
in girls
with
urinary
tract
and renal 1989;153:
of kidney infections
recognition,
3. Bisset GS Ill, Strife JL, Dunbar JS. Lkography
AJR
and
prevention
in of
and voiding cystourethinfection. AJR 1987;148:
Herniation of an Ovarian Cyst Through Canal: Diagnosis with CT
the lnguinal
We recently saw a woman who had a gigantic palpable abdominal mass caused by hemiation of a large ovarian cyst through the inguinal canal. To our knowledge, a similar case has not been reported before in the literature.
A 59-year-old
Physical examination
showed
woman
presented
a huge abdominal
with pain in the hip.
mass
15 x
15
x 20
cm. This soft-tissue mass could be palpated from the right groin to the umbilicus. It had no features of an inguinal hernia. The patient
had noticed this mass for many years but had not sought medical help. A sonogram showed that the mass was cystic but did not reveal the origin.
CT scan of the pelvis
showed
a large cystic
mass
arising
from the right ovary and herniating into the subcutaneous tissue via the inguinal canal (Fig. 1). At surgery, an enlarged cystic right ovary was found extending from the external to the internal inguinal ring in the right groin. The anterior wall of the canal was formed by the aponeurosis of the external oblique muscle, and the posterior wall was formed by the aponeurosis of the transversus muscle.
reflux require prolonged prophylactic therapy or perhaps even surgery. We agree that it is important to determine if renal scarring is present in patients who have urinary tract infection. This classically has been evaluated by using excretory urography. The frequency of renal scarring in girls studied by excretory urography [3] and in this study
[1]
question
in which
we
used
sonography
is almost
identical.
always is, How much does one investigate?-particularly
The
in
healthy outpatient girls who have documented urinary tract infections. Obviously, each additional imaging study (sonography, excretory urography, renal scintigraphy, cortical nuclear imaging) increases the detection of small renal scars. Our study did not compare renal sonography with nuclear scintigraphy with cortical labeling agents such as “Tc-glucoheptonate or
Fig. 1.-CT scan shows ovarIan cyst arising from right ovary (straight arrow) and herniating to subcutaneous tissue via inguinal canal. Curved arrow = bladder.
Although
the diagnosis of hernia almost always can be established CT may be useful in differentiating between a hernia and a mass within the abdominal cavity or abdominal wall [1]. Herniated inguinal ovaries in children and infants are not uncommon [2]. Herniaclinically,
tion
of
an
extremely
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tumor
203
LETTERS
AJR:154, January 1990
ovarian
mass
through
the
inguinal
canal
in
rare. We found
only one case in the literature hernia [3].
in an inguinal
Hans
3485
P. M. van
University CX Utrecht,
adults
W. Smit
A. Heitbrink Frans
Deventer Hospital the Netherlands
tomography
with
MA!
2. Kristiansen CT, Snijder WH Jr. Inguinal hemia in female infants and children. WestJ Surg 1956;64:481-484 3. Kawanchi H, Yashiro inguinal hemia. Rinsho
N, Ohtomo K, et al. A case Hoshasen 1986;31 :441-443
of ovarian
tumor
intragastric
in
the
in some
combination
patients
directly
the
I found
gastric that
the operating exposure
room)
to the
cannula
uterine
into
who
have
the
small
and
into
the
for a 6.5-French
duodenum.
cobra
At this
2 catheter,
point,
had
bowel
per-
without
were too
short
use was designed (readily available to prevent increased radiacannulas
hands.
of the University
Constantin Cope of Pennsylvania
Philadelphia,
dilator
1989;
I currently
malleable
Hospital
6.5French 20-cm dilator successfully on several occasions without difficulty. We perform the initial gastric puncture in the standard fashion. After placing the guidewire in the body of the stomach, we place a bend in the end of a 6.5-French dilator 1-2 cm from the tip. The dilator then is advanced over the guidewire and easily directed toward the pylorus. When the guidewire is withdrawn inside the dilator, the bend at the end of the dilator easily can probe the region of the pyloric canal atraumatically. The wire can be removed and contrast material injected if any doubt exists as to the location of the pylorus. Once the dilator is in or near the pyloric canal, we advance a 1 .5-mm
the dilator
However,
for Gastrojejunal
guidewire coils in the body and fundus of the stomach. We describe an alternative aid. We have used a standard
through
AJR
coiling.
Incidentally, because
We read with interest Dr. Constantin Cope’s recent letter [1] describing the use of a malleable, stainless-steel, hollow cannula as an aid for intubating the duodenum during percutaneous gastrojejunostomy. We too have encountered the same difficulty in trying to catheterize the duodenum without the use of such an aid; the
exchange
systems.
catheter-guidewire
tion
J-wire
catheterization.
cutaneous endoscopic gastrostomy, or who have an unusually high gastrostomy site or a long J-shaped stomach or both, and it is unusually difficult to reach and intubate the duodenum because of the complex S curve within the stomach that the operator must follow. It is under these conditions that I have found that a stiff, hollow, malleable cannula is invaluable. It can be used to straddle the body of the stomach and to provide enough leverage to advance a
from
Directable Cannula Catheterization
for gastrojejunal
Reply
guidewire
P. Kok
REFERENCES 1 . Lee JKT, Sagel 55. Stanley RJ. Computed body correlation, 2nd ed. New York: Raven, 1989:661
cannula
and Twedt have found that a bent-tip 6.3-French to a cobra catheter for performing percutaneous because of the dilator’s slightly increased stiffness and its ready availability. I agree that it is fairly easy in most cases to gain access to the duodenum by using simple stiff catheter and
Hospital Utrecht the Netherlands Frits
1 . Cope C. Directable 152: 1346
Drs. Pedersen dilator is superior gastrojejunostomy
Heesewijk
Martin
7400 GC Deventer,
is
of an ovarian
REFERENCE
Fatality
from
Hepatic
Hemangioma
Fine-Needle
Aspiration
Biopsy
PA
19104
of a
It has been stated that no proof exists that guided transhepatic fine-needle aspiration biopsy of hepatic hemangioma is hazardous [1, 2]. We report a case in which the patient died after such a procedure.
A 77-year-old
man had abdominal
CT at a regional hospital as part
of staging for adenocarcinoma of the prostate. A 1 0-cm hypodense subcapsular lesion was seen in the right lobe of the liver. CT-guided fine-needle aspiration biopsy was performed with a 21-gauge spinal needle. Two separate direct needle passes were made that entered the mass without encountering any intervening normal liver (Fig. 1).
we
which
is
advanced to the end of the wire. We then exchange the wire for an Amplatz superstiff wire and use the catheter and wire combination to catheterize the jejunum.
The method we describe is certainly less elegant than that of Dr. Cope. The only advantage of our technique is that it allows use of materials
readily
available
One possible drawback
in any interventional
radiology
department.
of our method is that once we exchange
the cobra
catheter,
conceivably
the
is advanced farther it could buckle back into the stomach as we no longer have the stiffness of the dilator holding our position in the pylorus. Practically speaking, however, this has not been a problem, most likely because the Amplatz wire we use is sufficiently stiff to prevent the catheter from buckling back into the stomach. dilatorfor
as the catheter
I. Pedersen Gordon Twedt
Mark Malcolm
Grow
Andrews
Medical
Center
AFB, MD 20331
Fig. 1.-77-year-old
man with giant hepatic hemangioma.
A, Noncontrast CT scan shows 21-gauge needle inserted directiy into giant hemangioma, which extended to liver capsule. B, CT scan obtained 5 mm after fine-needle aspiration biopsy shows a perihepatic hernatorna extending anteriorly from biopsy site. Biopsy yielded fresh blood only.
LETTERS
204
Pain developed
immediately
a CT scan obtained
shoulder,
and
a subcapsular
he-
extending from the biopsy site. The patient subsequently became hypotensive and had an emergency laparotomy. A bleeding hemangioma, a subcapsular hematoma, a small capsular tear, and free intraperitoneal hemorrhage were seen. The bleeding site was packed at this time, but the patient continued to bleed postoperatively. Embolization was attempted but was unsuccessful. This was followed by reexploration and further packing of the liver. The patient was transferred to our hospital. He remained stable for 2 days. Coagulation factors were normal. When the packing material was removed from the liver, extensive bleeding occurred, which necessitated blood transfusion, right hepatic Iobectomy, and repacking. Coagulopathy, sepsis, and multiple system failure ultimately resulted in death 28 days after admission. Hemangiomas cannot always be diagnosed with certainty when matoma
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in the tip of the patient’s
5 mm after biopsy showed
imaging
2 cm
thick
techniques
are
used.
In addition,
the
attending
clinician
Robert G. Gibney Charles H. Scudamore University
of British
Columbia
Vancouver General Hospital Vancouver, B.C., Canada V5Z 1M9 REFERENCES
1 . Taavitsainen
M, Kivisaari L. Is fine-needle biopsy of liver hemangioma hazardous? AdA 1987;148:231-232 2. Solbiati L, Livraghi T, De Pra L, et al. Fine-needle biopsy of hepatic hemangioma with sonographic guidance. AJR 1985;144:471-475
3. Cronan JJ, Esparza AR, Dortman GS, Ridlen MS. Paolella LP. Cavernous hemangioma of the liver: role of percutaneous biopsy. Radiology 1988; 166: 135-1 38
The Gibbs Phenomenon In his letter [1] on Willard Gibbs and the Gibbs phenomenon, Schenck rightfully emphasized the historical importance of this great scientist. However, he was incorrect in his statement that the letters Gibbs wrote to Nature are “the basis of the artifactual phenomenon routinely
seen
in MR
images.”
letters shows that Gibbs observed the first
n terms
in a Fourier
In fact,
a careful
reading
of these
that for S(x) equal to the sum of
series
expansion
of a function,
Senes
N=64
N=128
A
B *Gibbs
ibbsPhenomenon
Fig. 1.-Effect of truncating the Fourier series and the Gibbs phenomenon. A, A discontinuity in a function occurs when the function jumps abruptly from one value to another. An example is the step function, shown here, which has a constant value until it reaches the point at which It suddenly jumps to another constant value. (Gibbs actually described the case of the “sawtooth” function, but the argument can be generalized.) If a finite number of terms are included in the Fourier series representing such a
function, the Fourier series has broad oscillations about the value of the function in the neighborhood of the discontinuity, as shown. B and C, As the number of terms included in the series increases, oscillations maintain their approximate amplitude but are squeezed closer to the discontinuity. Behavior in A-C describes what happens when the series is truncated with a finite number of terms and is the basis of what properly is called truncation artifact. D, As the number of terms in the Fourier series increases without limit, an arbitrarily narrow band in the neighborhood of the discontinuity remains that overshoots the true value of the function by about 9% of the magnitude of the discontinuity. This overshoot eventually becomes too narrow for the human eye to detect. Persistence of this 9% overshoot, in the limit of an infinite number of terms, is the Gibbs phenomenon.
Admittedly,
appropriate
this is a semantical issue. However, perhaps it is most to use the term truncation artifact for the effect observed
in MR imaging
and reserve
the term
Gibbs originally described, an entity likely ever to come in contact.
Gibbs phenomenon for what with which few radiologists are
the
projection on the y-axis of the curve y limit S(x) near a discontinuity overshoots the values of the function [2, 3]. This is shown graphically in Figure 1 . The persistence of this overshoot in the limit of an infinite =
Huntington
without invisible
increase
the number of terms in the Fourier series
limit, the overshoot would become infinitely narrow and to the human eye. The ringing of a truncated Fourier series
near a discontinuity,
the true basis of the artifactual
phenomenon
now routinely seen in MR images, is a property of these series that has been apparent since their initial description. Unfortunately, the original meaning of the term Gibbs phenomenon has become blurred in the more recent applied mathematics literature [4].
Anthony R. Whittemore Medical Research Institutes
Pasadena,
number of terms simply cannot be observed in MR imaging because only finite time and real electronic devices are available. Even if we
could effectively
Phenomenon
may
not accept the radiologic diagnosis of hemangioma, especially in oncologic patients. As a result, biopsies of hemangiomas are done both intentionally and inadvertently [3]. This case illustrates that fineneedle aspiration biopsy of hepatic hemangioma is not without risk and emphasizes the recommendation that a route that traverses normal liver should always be sought when such biopsies of liver lesions are performed. Blake A. Terriff
now
AJR:154, January 1990
CA 91005
REFERENCES 1 . Schenck JF. Willard Gibbs and the Gibbs phenomenon. AJR 1989;152: 1127 2. Gibbs JW. Fourier series. Nature 1899;59:200, 606 3. Sansone G. Orthogonal functions. New York: lnterscience Publishers, 1959:144-148
4. Bracewell RN. The Fourier transform York: McGraw-Hill, 1978:209-211
and its applications,
2nd ed. New
AJR:154, January 1990
Reply
This
My letter was an attempt
to forestall the possibility
that the name
of Willard Gibbs would become embedded in the radiologic literature in a misspelled form. Dr. Whittemore has raised, correctly and adroitly, a second issue, of whether it is truly appropriate to use the term
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205
LETTERS
issue
Persons
tion of their smaller
remembered
adopted
in radiology,
prevalent
throughout
this usage will be in conflict the field of digital
signal
with that now
processing.
to be a manifestation
accomplishments
of another
and somewhat while greater
phenomenon:
misplaced
recogni-
achievements
are
insufficiently. John
Gibbs phenomenon when referring to intensity oscillations in images from truncated data sets. This issue also was discussed briefly in a previous publication [1]. In this context, it would have been better if I had written that Gibbs’s letters were “the basis of his name being associated with the artifactual phenomenon now routinely seen in MR images.” Precision in historical and mathematical matters would support Dr. Whittemore’s suggestion of using the term truncation artifact in place of Gibbs phenomenon. However, an examination of standard references such as Digital Filters [2] shows that even if
seems
often receive excessive
GE Corporate
Research
Schenck
and Development Center Schenectady, NY 12301
REFERENCES
1 . Schenck JF, Hart HR Jr. Foster TH, Edelstein WA, Hussain
MA. High
resolution magnetic resonance imaging using surface coils. In: Kressel HY, ed. Magnetic resonance annual. New York: Raven, 1986:123-160 2. Hamming RW. Digital filters, 2nd ed. Englewood Cliffs, NJ: Prentice-Hall, 1977
Letters are published at the discretion of the Editor and are subject to editing. Letters to the Editor must not be more than two double-spaced, typewritten pages. One or two figures may be included. Abbreviations should not be used. See Author Guidelines, page AS. Material being submitted or published elsewhere should not be duplicated in letters, of letters must disclose financial associations or other possible conflicts of interest.
and authors
Letters concerning a paper published in the AJR will be sent to the authors of the paper for a reply to be published in the same issue. Opinions expressed in the Letters to the Editor do not necessarily reflect the opinions of the Editor.
199
Letters .
.
Hypersensitivity In a recent
occurred
Reaction issue
of AJR,
During
Feczko
during a single-contrast
Barium
a death
that
barium enema. Allergic or anaphy-
lactic reactions to barium sulfate suspensions, although known for some time, are rare, and we feel justified in reporting an additional case of severe hypersensitivity reaction associated with barium enema. The patient was a 43-year-old woman who had had gastric partition for morbid obesity, cholecystectomy, and ventral hernia repair 7 years before.
Her
surgery
had been complicated
by subphrenic
I
#{149} ..
.
‘
:
#{149}
#{149}
:.
#{149}#{149}
:
.“.
‘1
:
‘
. .
REFERENCES
Enema
et al. [1] reported
.
abscess
PJ, Simms SM, Bakirci N. Fatal hypersensitivity
1 . Feczko barium
enema.
reaction during a
AJR 1989;1 53:275-276
2. Schwarz EE, Glick SN, Foggs MB, Silverstein GS. Hypersensitivity tions
after barium
enema
examination.
reac-
AJR 1984;143:
103-1 04 3. Gelfand DW, Sowers JC, DePonte KA, Sumner TE, Ott DJ. Anaphylactic and allergic reactions during double-contrast studies: is glucagon or barium suspension the allergen? AJA 1985;144:405-406
Reply
and multiple viscerocutaneous fistulas. She had a history of allergic reaction (urticaria?) to IV contrast material, but she had not had any side effects associated with earlier barium studies. She had a single-contrast barium enema in May 1988 for preoperative evaluation for a fistula repair. Immediately after completion of the study, the patient began having dyspnea and diffuse wheezing over both lungs, and extensive urticaria developed over her entire body. Her blood pressure was 1 1 0/82 mm Hg, and her respiratory rate was 30/mm. Her respiration improved slowly after she was given 50 mg of Benadryl (diphenhydramine hydrochloride) intramuscularly and oxygen. The itching and urticaria became progressively worse, and 1 00 mg of hydrocortisone was administered intramuscularly. Later, the patient had a limited upper gastrointestinal study with a nonionic contrast material after she was premedicated with prednisone. She experienced no side effects from that study. Most patients who have side effects from a barium enema have a history of allergy. It has been suggested that methylparaben, a preservative [2], or glucagon [3] may be responsible for allergic reactions that occur during barium enemas. In our case, the singlecontrast barium enema was performed without glucagon, and meth-
I thank Brenner et al. for their interest in my article [1 ] and for their report of a hypersensitivity reaction associated with a barium enema. Over the last several months, I have become aware of other serious allergic reactions that have occurred during diagnostic barium studies. Although these events are unusual, radiologists must be made aware of the possibility that such events may occur. At my institution, we currently have both epinephrine and Benadryl (diphenhydramine hydrochloride) available in all fluoroscopic suites because of these reactions. Brenner et al. make several good points. I also think that manufacturers should list all ingredients on the package, but the Food and Drug Administration does not require them to do so. Another fascinating point is that E-Z-EM, Inc., now has a warning about the possibility of allergic reactions to its products on its latest package inserts. This information appears to be a relatively recent addition to the package inserts and is printed in boldface type. Peter J. Feczko Henry Ford Hospital
ylparaben
REFERENCE
is not listed specifically
as one of the ingredients
in the
preparation(E-Z-EM Disposable Bariuma Enema, E-Z-EM, Inc., Westbury, NY) that we used. However, in cases reported in the literature, barium suspensions from the same company were used, and one of the patients had a positive response to methylparaben in hypersensitivity
tests
Detroit,
1 . Feczko barium
PJ, Simms SM, Bakirci N. Fatal hypersensitivity AJR 1989;153:275-276
Ml
48202
reaction during a
enema.
[2].
It would be highly desirable to have all ingredients listed on the package and the possibility of side effects stated in the description of all barium suspensions. Jeffrey
S. Brenner John O’NeiI
Jun V. Kaude University
of Florida,
College
Gainesville,
of Medicine
FL 32610
Low-Attenuation
Mediastinal
Masses
on CT
The pictorial essay by Glazer et al. [1] provides a comprehensive of cystic mediastinal masses. However, I recently have seen a case not mentioned in this differential diagnosis that I believe may be of general interest as an uncommon manifestation of a common disease. An 84-year-old woman had had dyspnea for several weeks, particularly when she was lying down. Screening chest radiography showed review
LETTERS
200
AJR:154,
January 1990
REFERENCE 1 . Glazer HS, Siegel MJ, Sagel 55. Low-attenuation CT.AJR
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mediastinal
masses on
1989;152:1173-1177
and Peptic Stricture
of the Esophagus
We describe an unusual case of tuberculosis complicating peptic stricture of the esophagus. A 45-year-old woman who had been having retrosternal burning for several years presented with dysphagia. A barium esophagogram showed a smooth stricture of the distal 5 cm of the esophagus (Fig. 1). The patient refused any intervention at this time and was treated antacids for peptic-acid disease. Five years later, she presented with worsening dysphagia. A repeat esophagogram showed no significant change in the degree of the stricture; however, multiple ulcerations were seen proximal to the stricture. No definite pathologic diagnosis could be made because the patient refused endoscopic biopsy. Six months later, she returned because of constant, dull, aching retrostemal pain. A barium esophagogram showed a localized with
Fig. 1.-A and B, CT scans show cystic mass in middle mediastinum. Trachea and superior vena cava are compressed (A), and mass extends up to thoracic
inlet on right side (B).
a mediastinal mass. CT scan showed a cystic mass in the middle mediastinum with compression of the trachea and superior vena cava (Fig. 1). The mass extended up to the thoracic inlet on the right. At mediastinal biopsy, the mass was soft but definitely encapsulated. The cystic part consisted of necrotic debris. Examination of biopsy specimens from the capsule showed poorly differentiated lymphocys-
tic lymphoma. Non-Hodgkin lymphoma presents as a purely mediastinal mass in less than 10% ofcases [2]. Primary mediastinal lymphoma presenting as a cystic mass in the mediastinum is a possibility not mentioned in either
the pictorial
essay
[2, 3]. As non-Hodgkin
or the two major textbooks
lymphoma
is a common
on CT scanning
disease,
I think that
probably will not be an isolated case and that non-Hodgkin lymphoma should be included in the differential diagnosis of cystic mediastinal masses. Jack T. English St. Francis Medical Center La Crosse, WI 54601 this
REFERENCES 1 . Glazer
HS, Siegel MJ, Sagel 55. Low-attenuation
CT.AJR
mediastinal
leak
of contrast
material
from
the
region
of the
ulceration
proximal to
the stricture. The patient agreed to have surgery, and a localized periesophageal abscess was excised along with the adjacent cardioesophageal junction. An esophagogastrostomy was performed. The patient’s recovery was uneventful. Histopathologic examination of the resected
specimen showed classic tuberculous granulation tissue in the wall of the esophagus, in relation to the ulcers. Lymph nodes surrounding the abscess also showed tuberculous granulation with caseation. Esophageal involvement in tuberculosis is seen at autopsy in less than 1 % of patients who have this disease [1]. Though such involvement invariably is associated with advanced pulmonary or mediastinal tuberculosis,
isolated
cases
of primary
esophageal
tuberculosis
have
been reported
[2]. In such cases, as in our patient, the diagnosis seldom is suspected preoperatively. Symptoms are often nonspecific and include dysphagia and chest pain [3]. Ulceration in peptic strictures of the esophagus occurs in the strictured segment itself. On the other hand, ulceration and perforation in an area proximal to a peptic stricture strongly suggests a nonpeptic cause of ulceration. The differential diagnosis for such proximal ulceration includes drug-induced esophagitis, herpetic or
masses on
1989;152:1173-1177
2. Sagel 55, Glazer HS. Mediastinum. In: Lee JKT, Sagel 55, Stanley RJ. Computed body tomography, 2nd ed. New York: Raven, 1989:245-294 3. Bick RJ, Haaga JR, Solemon EH. The mediastinum. In: Computed tomography
of the whole
body,
2nd ed. St. Louis: Mosby,
1988:570-648
Reply We thank Dr. English for describing his case of mediastinal nonHodgkin lymphoma. As stated in our article [1], any neoplasm with necrosis may have areas of low attenuation that often is not absolute but relative to the enhancing wall of the lesion or to surrounding structures on IV contrast-enhanced CT scans. Determination of the precise attenuation value in these cases actually discloses a density close to that of soft tissue, which we are certain is the situation in the submitted illustrations. This needs to be distinguished from true cystic
lesions
with
be seen in patients
attenuation
values
who have Hodgkin
near
those
of water
that
may
lymphoma.
Harvey S. Glazer Marilyn Stuart Mallinckrodt
Institute
St. Louis,
J. Siegel S. Sagel
of Radiology
MO 63110
Fig. 1.-Tuberculosis and peptic stricture of the esophagus. A, Initial esophagogram shows peptic stricture. B, Esophagogram obtained 5 years after A shows ulcerations
proximal to stricture. C, Esophagogram and leak of contrast
(arrows)
obtained 6 months after B shows local perforation material
(arrow).
candidial
wish
infection,
to stress
and
Crohn
disease
that in areas
nocompromised
patients,
and perforation
[2].
endemic
tuberculosis
proximal
With
this
case
for tuberculosis
to a peptic
report,
Akiyosi
we
and in immu-
Tokyo
Tokyo
REFERENCES 1 . Lockard LB. Esophageal tuberculosis: a critical review. Laryngoscope 1913;23:561 -584 2. Fahmy AR, Guindi R, Farid A. Tuberculosis of the esophagus. Thorax 1969;24:254-256 3. Rubinstein BN, Patrana T. Jacobson HG. Tuberculosis of the esophagus.
1 . Anthony PP, Telesinghe Pathol 1986;39:761-768
Inflammatory
unknown
[1 -4].
Pseudotumor pseudotumor
infiltration
is rare,
a case in which
and
the cause
the diagnosis
is still
was con-
multiple septa were seen after administration of (Fig. 1 A). Percutaneous needle biopsy of the tumor
examination
of inflammatory
of malignancy.
cells
No diagnosis
of the biopsy
in the
could
fibrous
specimen
tissue
and
showed
no evidence
...
:
.
;:;>
‘
,
‘‘..:“-
Investigation
infection
in girls.
radiographic
pseudotumor
A, Contrast-enhanced CT scan with enhancement of septa. B, Photomicrograph of specimen
of liver.
shows
multlloculated
obtained
at surgery
low-density 22 months
area after A
shows numerous lymphocytes and plasma cells in connective tissue cornposed of collagen fibers and fibroblasts. (H and E) At follow-up
and CT showed also showed a mosaiclike hypoechoic area 7 x 8 cm in diameter. Except for the size, the CT appearance was the same as before. An extended right lobectomy of the liver was performed. At surgery, a large solitary the
mass
22 months
had
increased
later,
both
sonography
in size.
Sonography
The
radiation.
This
protocol
jaundice
pseudotumor
and portal
of
hypertension
in a
Histologic examination cells in the connective and fibroblasts (Fig. 1 B).
of Urinary Tract Infection
Imazato
Yoshinori Eiko
Isobe Ueno
may
is the omission
entails become
of the standard
relatively the
positive results of urine cultures obtained clean-catch
high
procedure
exposure of choice
to
if its
specimens
from bagged specimens
in girls
(especially
in those
or less
than 2 years old) are frequent, and we wonder how many children really had urinary tract infections. Urethral catheterization and suprapubic aspiration of the urine are much more reliable methods for collecting urine specimens for determination of urinary tract infections [2,3]. Second, the authors state that reflux nephropathy develops when infected urine refluxes into the renal collecting system and into a refluxing papilla. This point is controversial, and experimental and clinical data appear to indicate that reflux nephropathy can develop in the absence of infection [4]. Strife
et al. minimize
the significance
of the inability
of nuclear
cystography to detect grade I reflux, stating that knowledge that a patient has grade I reflux rarely results in a change in therapy. On the contrary, although grade I reflux is not an indication for surgical correction, prolonged prophylactic antibiotic therapy uniformly is administered in this situation [5, 6]. Finally, Strife et al. correctly emphasize the importance of detecting renal scarring in patients who have urinary tract infection. However, they neglect a large body of evidence [7, 8] that shows that renal nuclear scanning with cortical agents such as “Tc-glucoheptonate
is more effective
than renal sonography
protocol
who have urinary
in children
performing cortical
in detecting
tract infection
a renal scan to determine
scars.
Our
and reflux includes
the presence
or absence
of
scars.
Morris
J. Schoeneman
C. Richard Goldfarb Fukiat Howard
Ongseng Finestone
Beth Israel Medical Center New York, NY 10003
showed numerous lymphocytes tissue composed of collagen fibers Masayuki
advantage which
results can be validated, and if the grading procedure based on the use of isotopes can be mastered by other groups. We have some concerns about the methods used in this study [1 ] and about some of the authors’ statements on the pathophysiology of reflux nephropathy and the treatment of grade I reflux. First, a definition of urinary tract infection is not provided. False-
mass in the right lobe with adhesion with the diaphragm was present. The lesion had a well-demarcated, irregular margin and was yellowish and white. and plasma
major
cystogram,
Third,
that
of obstructive
child. Pediatr Radiol 1984;14:433-435 3. Maeda M, Sakai V. Koyama W, et al. A case of inflammatory pseudotumor of the liver. Liver 1988;29:546-551 4. Yamauti T, Furui S. Ohtomo K, et al. A case of inflammatory pseudotumor of the liver. Nippon Igaku Hoshasen Gakkai Zasshi 1985;30: 1505-1508
midstream
be made.
1
Fig. 1.-Inflammatory
of the liver. J Clin
We were interested in the report by Strife et al. [1 ] describing changes in their protocol for the imaging evaluation of urinary tract
of the Liver
of the liver
We report
was done. Histologic
pseudotumor
-403
firmed at surgery. A 51-year-old man had had epigastric pain for 1 month. Endoscopy revealed a gastric ulcer, and sonography showed a tumor of the liver. CT showed a low density multiloculated lesion in the right lobe of the liver. Enhanced contrast material
PU. Inflammatory
2. Heneghan HA, Kaplan CG, Prieve CJ, et al. Inflammatory
Imaging
Inflammatory
College
162, Japan
REFERENCES
the liver: a rare cause
1958;70:401
Yamada
Medical
stricture. Ravi Ramakantan King Edward Memorial Hospital Bombay, 400 022, India
Radiology
Women’s
can be a cause of ulceration Priti Shah
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201
LETTERS
AJR:154, January 1990
REFERENCES 1 . Strife JL, Bisset sonography:
GS Ill, Kirks DR. et al. Nuclear cystography findings in girls with urinary tract infection. AJR
and renal 1989;153:
LETTERS
202
115-119 2.
‘Tc-dimercaptosuccinic
Ogra PL, Faden HS. Urinary tract infection
Pediatr 1985;106: 1023-1029 4. Hellerstein S. Recurrent urinary
tract
an update. J
in childhood:
infection
in children.
Pediatr
Infect
Dis 1982:1:271-281
Downloaded from www.ajronline.org by 69.11.182.82 on 10/19/15 from IP address 69.11.182.82. Copyright ARRS. For personal use only; all rights reserved
4. McCurdy
FA, Vemier RL. Unique consequences of kidney infections in infants and children: pathogenesis, early recognition, and prevention of scarring. Am J Nephrol 1981;1 :184-1 97 5. Report of the Intemational Reflux Study Committee. Medical versus surgical treatment of primary vesicoureteral reflux. Pediatrics 1981;67: 392-400 6. Aladjem M, Boichis H, Hertz management of vesicoureteral 1980;65:78-80 7. Stoller
AJR:154, January 1990
ML, Kogan
scanning
agents
considerably
acid.
is able
Renal
to show
scintigraphy
renal
higher dose of radiation.
these cortical
with
scarring,
although
Some institutions,
with
own, may proceed to a third study (excretory urography, renal scintigraphy with cortical scanning agents) in high-risk girls (e.g., less than 2 years old, infection with an unusual organism, failure to respond to appropriate antibiotic therapy). We do not recommend this detailed and aggressive imaging as a routine protocol for all
children who have urinary tract infection and reflux. Janet
M, Herzfeld
U. The conservative reflux: a review of 1 21 children. Pediatrics
BA. Sensitivity
5, Raviv
of “Tc-dimercaptosuccinic
diagnosis of chronic pyelonephritis:
Francis
acid for the
Dis
J. Schlueter
Michael J. Gelfand Diane S. Babcock Bokyung K. Han Children’s Hospital Medical Center Cincinnati, OH 45229-2899
acid (DMSA) Arch
L. Strife
George S. Bisset Ill Donald R. Kirks
clinical and theoretical considerations.
J Urol 1986;135:977-980 8. Verber IG, Strudley MR, Meller ST. “Tc-dimercaptosuccinic scan as first investigation of urinary tract infection.
a
including our
Child
1988:63: 1320-1 325
REFERENCES
Reply We are pleased,
experience infection
would
studies.
and in fact had hoped,
in evaluating stimulate
All patients
Radiology
interest,
[1] of our
of girls with urinary tract
discussion,
and
other
controlled
in our study were referred to the Department
at Children’s
had documented
that the report
a large number
Hospital
Medical
a urinary tract infection.
Center
by pediatricians
The standard
of who
definition
of
“significant” bacteriuria is growth of more than 1 00,000 coIonies/,l of a single organism in urine obtained by the clean-catch method. We agree that it is extremely important to obtain a specimen correctly in children so that they will not be mislabeled as having a urinary tract infection.
investigations
of vesicoureteral reflux, infection, and reflux nephropathy have been done over the past few decades. Although it remains controversial if reflux nephropathy can develop in the absence of infection, most agree that reflux provides a potential route for transporting organisms from the lower urinary tract to the Numerous
kidneys,
with possible
subsequent
renal infection
and scarring.
We
evaluated patients in our study only if they had a documented urinary tract infection. McCurdy and Vernier [2] concluded that “the knowl-
edge accumulated over the past 10 years suggests strongly that UTI associated with vesicoureteral reflux is a major cause of renal scarring and an important
cause
of renal failure
in children.”
The question
whether reflux nephropathy can develop in the absence was not addressed in our study. It is difficult
to diagnose
of nuclear cystography.
grade
I vesicoureteral
The length of prophylactic
reflux
of
of infection on the basis
therapy necessary
in patients with grade 0 and grade I reflux remains controversial. Nuclear cystography accurately detects higher grades of reflux; most clinicians agree that infants and children who have these grades of
1 . Strife JL, Bisset GS Ill, Kirks DR, et al. Nuclear cystography sonography: 115-119
2. McCurdy
findings
in girls
with
urinary
tract
infection.
FA, Vemier RI. Unique consequences
infants and children: pathogenesis, early scarring. Am J Nephrol 1981;1 :184-197 rography: 479-482
findings
in girls
with
urinary
tract
and renal 1989;153:
of kidney infections
recognition,
3. Bisset GS Ill, Strife JL, Dunbar JS. Lkography
AJR
and
prevention
in of
and voiding cystourethinfection. AJR 1987;148:
Herniation of an Ovarian Cyst Through Canal: Diagnosis with CT
the lnguinal
We recently saw a woman who had a gigantic palpable abdominal mass caused by hemiation of a large ovarian cyst through the inguinal canal. To our knowledge, a similar case has not been reported before in the literature.
A 59-year-old
Physical examination
showed
woman
presented
a huge abdominal
with pain in the hip.
mass
15 x
15
x 20
cm. This soft-tissue mass could be palpated from the right groin to the umbilicus. It had no features of an inguinal hernia. The patient
had noticed this mass for many years but had not sought medical help. A sonogram showed that the mass was cystic but did not reveal the origin.
CT scan of the pelvis
showed
a large cystic
mass
arising
from the right ovary and herniating into the subcutaneous tissue via the inguinal canal (Fig. 1). At surgery, an enlarged cystic right ovary was found extending from the external to the internal inguinal ring in the right groin. The anterior wall of the canal was formed by the aponeurosis of the external oblique muscle, and the posterior wall was formed by the aponeurosis of the transversus muscle.
reflux require prolonged prophylactic therapy or perhaps even surgery. We agree that it is important to determine if renal scarring is present in patients who have urinary tract infection. This classically has been evaluated by using excretory urography. The frequency of renal scarring in girls studied by excretory urography [3] and in this study
[1]
question
in which
we
used
sonography
is almost
identical.
always is, How much does one investigate?-particularly
The
in
healthy outpatient girls who have documented urinary tract infections. Obviously, each additional imaging study (sonography, excretory urography, renal scintigraphy, cortical nuclear imaging) increases the detection of small renal scars. Our study did not compare renal sonography with nuclear scintigraphy with cortical labeling agents such as “Tc-glucoheptonate or
Fig. 1.-CT scan shows ovarIan cyst arising from right ovary (straight arrow) and herniating to subcutaneous tissue via inguinal canal. Curved arrow = bladder.
Although
the diagnosis of hernia almost always can be established CT may be useful in differentiating between a hernia and a mass within the abdominal cavity or abdominal wall [1]. Herniated inguinal ovaries in children and infants are not uncommon [2]. Herniaclinically,
tion
of
an
extremely
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tumor
203
LETTERS
AJR:154, January 1990
ovarian
mass
through
the
inguinal
canal
in
rare. We found
only one case in the literature hernia [3].
in an inguinal
Hans
3485
P. M. van
University CX Utrecht,
adults
W. Smit
A. Heitbrink Frans
Deventer Hospital the Netherlands
tomography
with
MA!
2. Kristiansen CT, Snijder WH Jr. Inguinal hemia in female infants and children. WestJ Surg 1956;64:481-484 3. Kawanchi H, Yashiro inguinal hemia. Rinsho
N, Ohtomo K, et al. A case Hoshasen 1986;31 :441-443
of ovarian
tumor
intragastric
in
the
in some
combination
patients
directly
the
I found
gastric that
the operating exposure
room)
to the
cannula
uterine
into
who
have
the
small
and
into
the
for a 6.5-French
duodenum.
cobra
At this
2 catheter,
point,
had
bowel
per-
without
were too
short
use was designed (readily available to prevent increased radiacannulas
hands.
of the University
Constantin Cope of Pennsylvania
Philadelphia,
dilator
1989;
I currently
malleable
Hospital
6.5French 20-cm dilator successfully on several occasions without difficulty. We perform the initial gastric puncture in the standard fashion. After placing the guidewire in the body of the stomach, we place a bend in the end of a 6.5-French dilator 1-2 cm from the tip. The dilator then is advanced over the guidewire and easily directed toward the pylorus. When the guidewire is withdrawn inside the dilator, the bend at the end of the dilator easily can probe the region of the pyloric canal atraumatically. The wire can be removed and contrast material injected if any doubt exists as to the location of the pylorus. Once the dilator is in or near the pyloric canal, we advance a 1 .5-mm
the dilator
However,
for Gastrojejunal
guidewire coils in the body and fundus of the stomach. We describe an alternative aid. We have used a standard
through
AJR
coiling.
Incidentally, because
We read with interest Dr. Constantin Cope’s recent letter [1] describing the use of a malleable, stainless-steel, hollow cannula as an aid for intubating the duodenum during percutaneous gastrojejunostomy. We too have encountered the same difficulty in trying to catheterize the duodenum without the use of such an aid; the
exchange
systems.
catheter-guidewire
tion
J-wire
catheterization.
cutaneous endoscopic gastrostomy, or who have an unusually high gastrostomy site or a long J-shaped stomach or both, and it is unusually difficult to reach and intubate the duodenum because of the complex S curve within the stomach that the operator must follow. It is under these conditions that I have found that a stiff, hollow, malleable cannula is invaluable. It can be used to straddle the body of the stomach and to provide enough leverage to advance a
from
Directable Cannula Catheterization
for gastrojejunal
Reply
guidewire
P. Kok
REFERENCES 1 . Lee JKT, Sagel 55. Stanley RJ. Computed body correlation, 2nd ed. New York: Raven, 1989:661
cannula
and Twedt have found that a bent-tip 6.3-French to a cobra catheter for performing percutaneous because of the dilator’s slightly increased stiffness and its ready availability. I agree that it is fairly easy in most cases to gain access to the duodenum by using simple stiff catheter and
Hospital Utrecht the Netherlands Frits
1 . Cope C. Directable 152: 1346
Drs. Pedersen dilator is superior gastrojejunostomy
Heesewijk
Martin
7400 GC Deventer,
is
of an ovarian
REFERENCE
Fatality
from
Hepatic
Hemangioma
Fine-Needle
Aspiration
Biopsy
PA
19104
of a
It has been stated that no proof exists that guided transhepatic fine-needle aspiration biopsy of hepatic hemangioma is hazardous [1, 2]. We report a case in which the patient died after such a procedure.
A 77-year-old
man had abdominal
CT at a regional hospital as part
of staging for adenocarcinoma of the prostate. A 1 0-cm hypodense subcapsular lesion was seen in the right lobe of the liver. CT-guided fine-needle aspiration biopsy was performed with a 21-gauge spinal needle. Two separate direct needle passes were made that entered the mass without encountering any intervening normal liver (Fig. 1).
we
which
is
advanced to the end of the wire. We then exchange the wire for an Amplatz superstiff wire and use the catheter and wire combination to catheterize the jejunum.
The method we describe is certainly less elegant than that of Dr. Cope. The only advantage of our technique is that it allows use of materials
readily
available
One possible drawback
in any interventional
radiology
department.
of our method is that once we exchange
the cobra
catheter,
conceivably
the
is advanced farther it could buckle back into the stomach as we no longer have the stiffness of the dilator holding our position in the pylorus. Practically speaking, however, this has not been a problem, most likely because the Amplatz wire we use is sufficiently stiff to prevent the catheter from buckling back into the stomach. dilatorfor
as the catheter
I. Pedersen Gordon Twedt
Mark Malcolm
Grow
Andrews
Medical
Center
AFB, MD 20331
Fig. 1.-77-year-old
man with giant hepatic hemangioma.
A, Noncontrast CT scan shows 21-gauge needle inserted directiy into giant hemangioma, which extended to liver capsule. B, CT scan obtained 5 mm after fine-needle aspiration biopsy shows a perihepatic hernatorna extending anteriorly from biopsy site. Biopsy yielded fresh blood only.
LETTERS
204
Pain developed
immediately
a CT scan obtained
shoulder,
and
a subcapsular
he-
extending from the biopsy site. The patient subsequently became hypotensive and had an emergency laparotomy. A bleeding hemangioma, a subcapsular hematoma, a small capsular tear, and free intraperitoneal hemorrhage were seen. The bleeding site was packed at this time, but the patient continued to bleed postoperatively. Embolization was attempted but was unsuccessful. This was followed by reexploration and further packing of the liver. The patient was transferred to our hospital. He remained stable for 2 days. Coagulation factors were normal. When the packing material was removed from the liver, extensive bleeding occurred, which necessitated blood transfusion, right hepatic Iobectomy, and repacking. Coagulopathy, sepsis, and multiple system failure ultimately resulted in death 28 days after admission. Hemangiomas cannot always be diagnosed with certainty when matoma
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in the tip of the patient’s
5 mm after biopsy showed
imaging
2 cm
thick
techniques
are
used.
In addition,
the
attending
clinician
Robert G. Gibney Charles H. Scudamore University
of British
Columbia
Vancouver General Hospital Vancouver, B.C., Canada V5Z 1M9 REFERENCES
1 . Taavitsainen
M, Kivisaari L. Is fine-needle biopsy of liver hemangioma hazardous? AdA 1987;148:231-232 2. Solbiati L, Livraghi T, De Pra L, et al. Fine-needle biopsy of hepatic hemangioma with sonographic guidance. AJR 1985;144:471-475
3. Cronan JJ, Esparza AR, Dortman GS, Ridlen MS. Paolella LP. Cavernous hemangioma of the liver: role of percutaneous biopsy. Radiology 1988; 166: 135-1 38
The Gibbs Phenomenon In his letter [1] on Willard Gibbs and the Gibbs phenomenon, Schenck rightfully emphasized the historical importance of this great scientist. However, he was incorrect in his statement that the letters Gibbs wrote to Nature are “the basis of the artifactual phenomenon routinely
seen
in MR
images.”
letters shows that Gibbs observed the first
n terms
in a Fourier
In fact,
a careful
reading
of these
that for S(x) equal to the sum of
series
expansion
of a function,
Senes
N=64
N=128
A
B *Gibbs
ibbsPhenomenon
Fig. 1.-Effect of truncating the Fourier series and the Gibbs phenomenon. A, A discontinuity in a function occurs when the function jumps abruptly from one value to another. An example is the step function, shown here, which has a constant value until it reaches the point at which It suddenly jumps to another constant value. (Gibbs actually described the case of the “sawtooth” function, but the argument can be generalized.) If a finite number of terms are included in the Fourier series representing such a
function, the Fourier series has broad oscillations about the value of the function in the neighborhood of the discontinuity, as shown. B and C, As the number of terms included in the series increases, oscillations maintain their approximate amplitude but are squeezed closer to the discontinuity. Behavior in A-C describes what happens when the series is truncated with a finite number of terms and is the basis of what properly is called truncation artifact. D, As the number of terms in the Fourier series increases without limit, an arbitrarily narrow band in the neighborhood of the discontinuity remains that overshoots the true value of the function by about 9% of the magnitude of the discontinuity. This overshoot eventually becomes too narrow for the human eye to detect. Persistence of this 9% overshoot, in the limit of an infinite number of terms, is the Gibbs phenomenon.
Admittedly,
appropriate
this is a semantical issue. However, perhaps it is most to use the term truncation artifact for the effect observed
in MR imaging
and reserve
the term
Gibbs originally described, an entity likely ever to come in contact.
Gibbs phenomenon for what with which few radiologists are
the
projection on the y-axis of the curve y limit S(x) near a discontinuity overshoots the values of the function [2, 3]. This is shown graphically in Figure 1 . The persistence of this overshoot in the limit of an infinite =
Huntington
without invisible
increase
the number of terms in the Fourier series
limit, the overshoot would become infinitely narrow and to the human eye. The ringing of a truncated Fourier series
near a discontinuity,
the true basis of the artifactual
phenomenon
now routinely seen in MR images, is a property of these series that has been apparent since their initial description. Unfortunately, the original meaning of the term Gibbs phenomenon has become blurred in the more recent applied mathematics literature [4].
Anthony R. Whittemore Medical Research Institutes
Pasadena,
number of terms simply cannot be observed in MR imaging because only finite time and real electronic devices are available. Even if we
could effectively
Phenomenon
may
not accept the radiologic diagnosis of hemangioma, especially in oncologic patients. As a result, biopsies of hemangiomas are done both intentionally and inadvertently [3]. This case illustrates that fineneedle aspiration biopsy of hepatic hemangioma is not without risk and emphasizes the recommendation that a route that traverses normal liver should always be sought when such biopsies of liver lesions are performed. Blake A. Terriff
now
AJR:154, January 1990
CA 91005
REFERENCES 1 . Schenck JF. Willard Gibbs and the Gibbs phenomenon. AJR 1989;152: 1127 2. Gibbs JW. Fourier series. Nature 1899;59:200, 606 3. Sansone G. Orthogonal functions. New York: lnterscience Publishers, 1959:144-148
4. Bracewell RN. The Fourier transform York: McGraw-Hill, 1978:209-211
and its applications,
2nd ed. New
AJR:154, January 1990
Reply
This
My letter was an attempt
to forestall the possibility
that the name
of Willard Gibbs would become embedded in the radiologic literature in a misspelled form. Dr. Whittemore has raised, correctly and adroitly, a second issue, of whether it is truly appropriate to use the term
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205
LETTERS
issue
Persons
tion of their smaller
remembered
adopted
in radiology,
prevalent
throughout
this usage will be in conflict the field of digital
signal
with that now
processing.
to be a manifestation
accomplishments
of another
and somewhat while greater
phenomenon:
misplaced
recogni-
achievements
are
insufficiently. John
Gibbs phenomenon when referring to intensity oscillations in images from truncated data sets. This issue also was discussed briefly in a previous publication [1]. In this context, it would have been better if I had written that Gibbs’s letters were “the basis of his name being associated with the artifactual phenomenon now routinely seen in MR images.” Precision in historical and mathematical matters would support Dr. Whittemore’s suggestion of using the term truncation artifact in place of Gibbs phenomenon. However, an examination of standard references such as Digital Filters [2] shows that even if
seems
often receive excessive
GE Corporate
Research
Schenck
and Development Center Schenectady, NY 12301
REFERENCES
1 . Schenck JF, Hart HR Jr. Foster TH, Edelstein WA, Hussain
MA. High
resolution magnetic resonance imaging using surface coils. In: Kressel HY, ed. Magnetic resonance annual. New York: Raven, 1986:123-160 2. Hamming RW. Digital filters, 2nd ed. Englewood Cliffs, NJ: Prentice-Hall, 1977
Letters are published at the discretion of the Editor and are subject to editing. Letters to the Editor must not be more than two double-spaced, typewritten pages. One or two figures may be included. Abbreviations should not be used. See Author Guidelines, page AS. Material being submitted or published elsewhere should not be duplicated in letters, of letters must disclose financial associations or other possible conflicts of interest.
and authors
Letters concerning a paper published in the AJR will be sent to the authors of the paper for a reply to be published in the same issue. Opinions expressed in the Letters to the Editor do not necessarily reflect the opinions of the Editor.
