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AIM: To evaluate the usefulness of computed tomography (CT) enteroclysis in patients with obscure gastrointestinal (GI) bleeding. MATERIALS AND METHODS: In a prospective study, CT enteroclysis was performed in 21 patients (median age 50 years; range 13-71 years) with obscure GI bleeding in which the source of the bleeding could not be detected despite the patient having undergone both upper GI endoscopic and colonoscopic examinations. The entire abdomen and pelvis was examined in the arterial and venous phases using multisection CT after distending the small intestine with 2l of 0.5% methylcellulose as a neutral enteral contrast medium and the administration of 150ml intravenous contrast medium. RESULTS: Adequate distension of the small intestine was achieved in 20 of the 21 (95.2%) patients. Potential causes of GI bleeding were identified in 10 of the 21 (47.6%) patients using CT enteroclysis. The cause of the bleeding could be detected nine of 14 (64.3%) patients with overt, obscure GI bleeding. However, for patients with occult, obscure GI bleeding, the cause of the bleeding was identified in only one of the seven (14.3%) patients. The lesions identified by CT enteroclysis included small bowel tumours (n=2), small bowel intussusceptions (n=2), intestinal tuberculosis (n=2), and vascular lesions (n=3). All vascular lesions were seen equally well in both the arterial and venous phases. CONCLUSIONS: The success rate in detection of the cause of bleeding using CT enteroclysis was 47.6% in patients with obscure GI bleeding. The diagnostic yield was higher in patients with overt, obscure GI bleeding than in those with occult obscure GI bleeding.

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PURPOSE: To study the role of self-expandable metallic stents in malignant esophageal strictures in terms of patency, improved dysphagia score, and possible associated complications. MATERIAL AND METHODS: Twenty-two patients with inoperable carcinoma of the esophagus underwent stent placement. Four different varieties of covered stents were used. Stenting was performed under fluoroscopic guidance and local pharyngeal anesthesia. During follow-up, patients were examined clinically and radiologically to assess the effectiveness of stents in relieving dysphagia, to check the stent position, patency, and possible complications. RESULTS: Fluoroscopic placement of the stent was successful and well tolerated in all patients without any serious complications. Accurate stent placement was possible in 95% of cases. The mean dysphagia score prior to stenting was 3.5 and poststent 1.2, with an improvement of 2.3 degrees. In two patients with associated fistulas, complete closure was seen after stent insertion. There was poor stent expansion in three patients. Significant tumor overgrowth occurred in two patients, and a second overlapping stent was deployed in one case. Three patients developed food impaction, which needed endoscopic removal of impacted food in two cases. CONCLUSION: Fluoroscopic placement of self-expandable metallic stents is a safe and effective method of palliating severe dysphagia and fistulas in patients with inoperable esophageal carcinoma. However, complications such as tumor overgrowth and food impaction may require reintervention after stent placement.

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In this report we describe a rare association of pachydermoperiostosis with protein-losing enteropathy (PLE) in a family of three brothers. The first brother had the complete form of pachydermoperiostosis along with PLE. The second brother had the 'forme fruste' of pachydermoperiostosis, with minimal skin changes, bony abnormalities and PLE, which was due to intestinal lymphangiectasia. The third brother had an incomplete form of pachydermoperiostosis without evidence of PLE. To our knowledge, the association of pachydermoperiostosis with PLE due to intestinal lymphangiectasia has not been reported previously.

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BACKGROUND: This retrospective analysis evaluated the clinical and radiologic results of transcatheter arterial embolization (TAE) in the treatment of significant hemobilia. The imaging findings, embolization technique, complications, and efficacy are described. METHODS: Thirty-two consecutive patients (21 male, 11 female, age range 8-61 years) who were referred to the radiology department for severe or recurrent hemobilia were treated by TAE. Causes of hemobilia were liver trauma (n = 19; iatrogenic in six and road traffic accident in 13), vasculitis (n = 6), vascular malformations (n = 2), and hepatobiliary tumors (n = 5). Iatrogenic liver trauma was secondary to cholecystectomy in those six patients. Four of five hepatobiliary tumors were inoperable malignant tumors and one was a giant cavernous hemangioma. Arterial embolization was done after placing appropriate catheters as close as possible to the bleeding site. Embolizing materials used were Gelfoam, polyvinyl alcohol particles or steel coils, alone or in combination. Postembolization angiography was performed in all cases to confirm adequacy of embolization. Follow-up color Doppler ultrasound and contrast-enhanced computed tomography was done in all patients. RESULTS: Ultrasonic, computed tomographic, and angiographic appearances of significant hemobilia were assessed. Angiogram showed the cause of bleeding in all cases. Three patients with liver trauma due to accidents required repeat embolization. Eight patients required surgery due to failed embolization (continuous or repeat bleeding in four patients, involvement of the large extrahepatic portion of hepatic artery in two, and coexisting solid organ injuries in two). Severity of hemobilia did not correlate with grade of liver injury. All 13 patients with blunt hepatic trauma showed the cause of hemobilia in the right lobe. No patient with traumatic hemobilia showed an identifiable cause in the left lobe. There were no clinically significant side effects or complications associated with TAE except one gallbladder infarction, which was noted at surgery, and cholecystectomy was performed with excision of the hepatic artery aneurysm. CONCLUSION: TAE is a safe and effective interventional radiologic procedure in the nonoperative management of patients who have significant hemobilia.

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The authors describe two patients with leiomyoma of the bladder who presented with bladder outlet obstruction. The results of magnetic resonance imaging are presented and their management discussed. Complete resection was curative in both patients, by enucleation in the first case and by transurethral resection in the second.

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Pancreatic divisum is the most common congenital anomaly of the pancreas but its association with choledochal cyst is extremely rare. We describe here a case of pancreatic divisum with choledochal cyst with a stone which was successfully treated at surgery. The common congenital pancreaticobiliary abnormalities are briefly discussed.

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We present an unusual case in which an impacted calculus at the lower end of the common bile duct produced massive dilatation. This resulted in a confusing picture of choledochal cyst on abdominal ultrasound and endoscopic retrograde pancreatography. The common bile duct returned to normal size after removal of the stone.

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