Biomedical subjects
Publications and source records attributed to B A Ellman.
Seventy-three cases of obstruction due to a bolus of Ascaris worms are reviewed. The diagnosis was made on the basis either of a characteristic palpable mass or a characteristic radiographic appearance. In 67 cases conservative treatment was successful. Six patients came to surgery, 5 because of deterioration. There were no deaths. The need for careful reassessment is stressed.
Traumatic arteriovenous fistula (AVF) is an uncommon form of vascular disruption. We reviewed 70 AVFs in 69 patients. Nearly one in ten acute arterial injuries is an AVF. Only half of these lesions, however, are clinically demonstrable. Iatrogenic lesions were present in 13% of patients. Eighty-one percent of lesions were treated surgically. Extracranial-intracranial (EC-IC) vascular bypass was used in over one third of head and high neck AVFs. Embolization was used as an adjunct to surgery in about one fourth of patients, and fewer than one in ten were treated with embolization alone. Since half of these lesions are not clinically detectable, liberal use of angiography is necessary for all traumatic wounds in proximity to a major vascular structure. Embolization was useful both as a primary treatment of AVF and as an adjunct to surgery; EC-IC bypass facilitates treatment of inaccessible fistulae in the head and neck.
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Control of acute variceal bleeding by transhepatic embolization was investigated in 14 patients with alcoholic liver disease. In these patients hemorrhage was unresponsive to general supportive measures, intravenous vasopressin and balloon tamponade. Embolization was performed using Gelfoam and a synthetic polymer, bucrylate. Acute hemorrhage was arrested in 86 percent of patients. Rebleeding after transhepatic embolization occurred in 35 percent of patients. There were three deaths from intraabdominal hemorrhage related directly to transhepatic embolization (21 percent). Six patients (43 percent) left the hospital alive. In a group of cirrhotic patients in whom transhepatic embolization was employed after traditional modes of therapy had failed to control variceal hemorrhage, mortality and rebleeding rates were high.
Many patients with cirrhosis and portal hypertension demonstrate a right-to-left shunt, caused by development of anastomoses connecting the high-pressure periesophageal veins with the low-pressure bronchial and/or pulmonary veins at the level of the pulmonary hili. These anastomoses from the pathway by which small Gelfoam particles injected into the coronary or short gastric veins may embolize the systemic arterial circulation. Such embolization could have serious consequences, but reports of such complications have not been found by the authors.
Transcatheter injection of absolute ethanol into the renal artery is an effective method of producing renal ablation. There has been no evidence of inadvertent damage to vessels or tissues remote from the target organ. The "postembolization syndrome" of pain, nausea, vomiting, and fever is minimal when compared with other methods of renal artery occlusion. Multiple mechanisms of action of intraarterial ethanol are proposed, including perivascular tissue toxicity, sludging of erythrocytes in small arteries, small artery spasm, and endothelial damage. Experience with this technique in six patients has resulted in specific recommendations regarding the amount and method of injection of ethanol. Angiographic criteria indicating adequate renal ablation are described.
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Radiographs from 30 children with intestinal obstruction caused by a bolus of Ascaris worms were analyzed. Worms could be seen outlined against intestinal gas; the interface between worm bolus and adjacent gas shadows was irregular. Gas trapped within the worm bolus had irregular outlines. There were also fine linear radiolucent shadows and small bubbles. Fluid levels were sometimes distorted by a projecting worm bolus, resulting in a hump effect. Some of the radiolucencies were within the worms. These features were used in an analysis of radiographs from 68 children who did not have bolus obstruction. Of 44 children with proven ascariasis, 28 (64%) had suggestive radiologic features. In four of 24 children without Ascaris ova in the stools, confusion with fecal shadows resulted in a false-positive diagnosis on the radiographs. Recognition of the worm infestation in asymptomatic patients is important because intestinal malabsorption may contribute to nutritional deficiency.
Accidental intra-arterial injection of intramuscular antibiotic preparations is described in 3 cases in infants. In 2 benzathine penicillin was injected, and in 1 rolitetracycline. The clinical features are dominated by arteriolar obstruction which produces gangrene of the most severely affected limb. In addition, neuroloigcal involvement occurs when vessels to nerves or spinal cord are involved. The arteriolateral aspect of the thigh is preferable to the buttock as a site for intramuscular injection, and a short (2.5 cm) needle should be used to minimise the risk of intra-arterial injection.
Gangrene of an extremity is very uncommon in measles, but we have encountered 3 cases. One patient had a peripheral variety with gangrene of the toes, while the other 2 had major vessel thrombosis. Evidence from the literature is advanced to support the hypothesis that disseminated intravascular coagulation on an immunological basis may be an important precipitating factor. Treatment is briefly discussed.
Selective renal artery catheterization was undertaken in a series of mongrel dogs. Absolute ethanol was injected on a dose/weight ratio. Venous blood ethanol levels were monitored. Pre- and postprocedure angiography was performed to evaluate the effectiveness of the injection. The dogs were subsequently sacrificed and pathologic examination performed. Renal infarction was produced in all animals. Systemic blood alcohol levels remained consistently below established criteria of toxic levels. No evidence of vascular damage in systemic arteries distal to the renal artery was found. Absolute ethanol is apparently a safe and effective method of producing permanent renal infarction.
The mechanism of renal ablation by intra-arterial ethanol was studied in 16 mongrel dogs. Ethanol injection rates were varied, and light and electron microscopic studies were performed to detect early parenchymal changes in the kidneys. Pure ischemic injury was also studied as a control. Findings showed extensive parenchymal injury plays a significant role in renal ablation with permanent thrombosis as a delayed event. Acute arterial occlusion occurred with slow ethanol injection rates due to embolization by damaged blood components.