Hypotonic Duodenography A refinement of the method involves use of the Seldinger technique. After introduction of the Studies using pharmacologic agents to alter gas- needle, a soft flexible guide wire is passed through trointestinal physiology are extending the potential the needle into the trachea. The needle is removed of diagnostic roentgenology. A fertile field of ex- and a catheter is inserted over the guide wire. ploration has been the duodenal loop. This area Bronchi may then be selectively catheterized with has always been difficult to examine and, because the aid of preshaped tips, tip control devices or of spasm or rapid peristalsis, subtle changes reflect- magnetic tip control. ing a disease process in the adjacent pancreas may be missed. Hypotonic duodenography, by inducing HowAiw M. LEVINSON, M.D. temporary paralysis with the anticholinergic drug REFERENCES propantheline bromide, allows a detailed demon- Cope C: Selective bronchial catheterization by a new percutaneous, stration of the anatomy of the duodenal loop. transtracheal technique. Amer J Roentgenol 96:932-935, 1966 Casarella WJ, Driller J, Hilal SK: A magnetically guided bronchial Tubeless methods were used for many years. catheter of modified POD design. Radiology 93:930-932. 1969 Sargent NE, Tumer PA: Catheter tip deflection system for selec- Recent methods involve intubation of the duode- tive bronchography. Radiology 93:936-939, 1969 num, followed by the administration of 60 mg of propantheline bromide by intramuscular injection. This gives effective atony for about 20 minutes. The duodenum is then distended with barium and Contrast Laryngography air under fluoroscopic control. Urinary retention is occasionally a problem, so The contrast laryngogram has proved itself a the procedure should be done with caution in the valuable addition to the armamentarium in both presence of prostatic enlargement. Glaucoma is diagnostic and therapeutic radiology. After pre- also said to be a contraindication. A dry mouth, medication with atropine, topical anesthesia of the some pupil dilatation, and blurred vision or tachy- hypopharynx is accomplished by spray or inhala- cardia are other effects of the drug. tion nebulizer. A long metal cannula is placed on Signs of abnormality on hypotonic duodenogra- the dorsum of the tongue, and approximately 10 phy such as effacement or spiculation of the mu- ml of oily contrast material is slowly dripped into cosa are similar to ordinary gastrointestinal roent- the hypopharynx. Fluoroscopic spot films are then genographic studies, except these signs tend to be made in antero-posterior and lateral projections accentuated and more reproducible. with the patient erect. Exposures are usually made during inspiration, phonation, Valsalva and modi- DOUGLAS J. SHEFT, M.D. fied Valsalva maneuvers. Detailed view of hypo- REFERENCES pharyngeal and laryngeal anatomy is routinely is of Bilboa MK, Frische LH, Dotter CT, et al: Hypotonic duodenogra. obtained. The procedure the greatest value phy. Radiology 89:438-443, 1967 in the clinical staging of hypopharyngeal carcino- Jacquemet P, Liotta D, Mallet-Guy P: Early radiological diagnosis of diseases of the pancreas and ampulla of Vater. Springfield, illinois, ma, but also is helpful in cases of laryngeal trauma. CC Thomas, 1965 It is particularly valuable in evaluating the sub- glottic space, which is difficult to assess even with direct laryngoscopy. GEORGE R. LEOPOLD, M.D. Percutaneous Transtracheal Bronchography REPERENCES Powers WE, McGee HH Jr, Seaman WB: Contrast examination of The transcricothyroid approach to the tracheo- the larynx and pharynx. Radiology 68:169-178, 1957 Powers WE, Holtz S, Ogura J, et al: Contrast examination of larynx bronchial tree provides a convenient, safe and and pharynx: Accuracy and value in diagnosis. Amer J Roentgenol relatively comfortable technique for bronchogra- 86:651-660, 1961 phy. The simplest method is use of the intracath used commonly for venous cannulation. After the skin has been anesthetized, the needl-e of the intracath is inserted through the cricothyroid mem- Pulmonary Leiomyoma brane. The polyethylene tube is then passed into The world literature has a total of 21 proved the trachea and either or both bronchial trees may cases of pulmonary leiomyoma, and it is a seldom then be opacified with oily dionosil. considered histologic diagnosis in cases of a pri-

CALIFORNIA MEDICINE 63 The Western Journal of Medicine mary lung mass. Sweets recently reported a case the rapid injection of the pyelographic medium. of a 3 cm right lower lung solitary nodule in a 21- Particular features searched for on such hyper- year-old asymptomatic male. Isotope scanning tension pyelograms are differences in the size of of the lung and selective pulmonary arteriography the kidneys, their calyces, and the appearance time were of no diagnostic value, and at thoracotomy and concentration of the excreted opaque. False the lesion was well encapsulated and completely positive and false negative results occur, and there resectable. are screening procedures that are said to be more As a rule, these lesions are totally asymptomatic, accurate. However, the simplicity of the rapid fortuitously discovered, and histologically com- sequence ivP and its universal availability con- pletely benign. tinue to make it the most widely used radiologic Reviewing the literature of all known reported screening procedure in the examination of unex- lesions, Sweet noted they characteristically are plained hypertension. slow in growth and infrequently calcified. They A. J. PALUBINSKAS, M.D. may be endobronchial or intraparenchymal. ROBERT H. REID, M.D. REFERENCES Cocket AJ, Maxwell M, Kaufman JJ: Delayed appearance time of intrvenous urographic contrast media in renal ichemi hypertension. REFERENCE J Urology 87:799-804, 1962 Shapiro R, Doppman J. Gabriele OF: The radioogst and the prob Sweet RS, Major MC: Pulmonary leiomyoma. Amer J Roentgenol lem Of renal vascular hypertension. Amer J Roen l 95:389-402, 107:823-826, 1969 1965 Levitt X1, Amplatz K, Loken MK: Renovascular hyprension. Radi. ology 91:521-528, 1968

Frequency of Urinary Tract Abnormalities in Sickle Cell Disease Radionuclide Studies of Pulmonary Ventilation and Perfusion Renal medullary structural damage from sickling with stasis and infarction often results in bilateral A complete evaluation of regional lung function caliectasis and poor concentration of contrast should include examination of both the distribution media by the kidney (isosthenuria). of air throughout the lungs as well as the perfusion Caliectasis not related to the presence or the of blood to the lungs. By using modern radio- absence of urinary tract symptoms was found in nuclide imaging techniques, alterations in the 7 of 17 cases. No cases of unequivocal renal papil- normal patterns of regional ventilation and per- lary necrosis were found. Intravenous drip tech- fusion often can be demonstrated before pathologic nique provides decidedly improved opacification changes are recognized on standard chest radiog- of the renal collecting system and should be udlized raphy. routinely in patients with sickle cell disease. Radionuclide studies of lung perfusion can be GEOFFREY A. FiCKER, M.D. accomplished either by injecting radioactive labeled particles (10 to 60 microns) intravenously REFERENCES or by a more central injection of a radioactive Margulies SI, Sanford D: Minkin sickle cell disease. Amer J Roent. inert gas such as xenon-133 dissolved in saline genol 107:702-710, 1969 solution. The resulting image of the distribution Cochrn RT Jr: Hyposthenuria in sickle cell states. Arch Int Med 112:222-225, 1963 of these materials in the lung, as recorded with a device such as the scintillation camera, indicates the relative regional perfusion of blood. Regional ventilation is evaluated by having the patient breath a mixture of air containing a small quantity Rapid Sequence ivp in Hypertension of xenon-133 gas. Comparison of the perfusion A simple modification of the routine intravenous lung scan, or picture of blood flow, with the image pyelogram has found universal acceptance in the of ventilation permits effective study of early examination of patients suspected of having reno- changes associated with almost all types of pul- vascular hypertension. The modification consists monary disorders. These techniques have been of the inclusion of several time-spaced films of most valuable in patients suspected of having pul- the kidneys within the first several minutes after m-onary embolization, chronic brhitis, emphy-

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