		Academic Chief of Musculoskeletal Imaging

	Each month, Dr. Maria Flynn issues a Radiology Challenge, presenting images from one of a variety of imaging modalities and a case report. Can you diagnose the condition? Follow the link to find out whether your answer was correct, what was really wrong with the patient, and how the patient was treated. Then, come back next month to test your radiographic reading skills on a new case!

	A 52-year-old man with a history of traveling to remote locations presented to his primary care physician because of intermittent midabdominal discomfort that had started 2 to 3 weeks earlier. Physical examination and routine laboratory analysis were unremarkable. Contrast-enhanced computed tomography (CT) scans of the abdomen and pelvis showed a small bowel filling defect (Figures).

 What is causing the small bowel filling defect?

		Helminthic infections are one the most prolific parasitic diseases to afflict humans. 

 is the most common infectious organism within the helminthic species and affects more than 1.4 billion individuals worldwide; this is 25% of the world's population.

 Four million individuals are infected annually in the United States. These cases are associated primarily with immigrants to the country. Globally, 12 million new cases are reported annually, and there are between 10,000 and 20,000 deaths per year.

 is usually associated with poor sanitation and rudimentary agricultural practices, such as using human feces or "night soil" to enrich vegetable beds. Ascariasis is most commonly observed in children between 4 and 10 years of age and is considered a significant component of intellectual deterioration and malnutrition in areas where this disease is prevalent.

		Historically, intestinal parasitic infections have been viewed as diseases related to lower socioeconomic classes. With the increasing globalization of markets and economies, agricultural products once obtained from farms within our borders are imported from countries that do not adhere to the same stringent agricultural practices.

 Efficient and rapid transportation, in conjunction with a world market, have facilitated the access of infectious diseases to every economic hub. As a result, medical systems around the world must remain vigilant for outbreaks of infections that previously were relegated to isolated and impoverished regions.

 begins with the fertilization of an ovum within the human small intestine, normally the jejunum. The fertilized egg is excreted into the environment, and embryonation occurs approximately 3 to 6 weeks later. The eggs can remain viable in warm, moist soil for approximately 72 months. Because these eggs are resistant to the chemical and environmental degradation that is known to inactivate the majority of pathogens, many research laboratories use 

 After the embryonated eggs are ingested, they hatch into larvae. These larvae invade the intestinal mucosa and proceed through the portal system and systemic circulation until they reach the lungs. The young larvae reside there and mature for a period of 1 to 2 weeks before penetrating the alveolar walls. After penetrating the bronchial airway, the larvae migrate into the posterior pharynx, where they are again ingested. The larvae develop into mature worms within the jejunum, where they can survive for approximately 1 to 2 years. A female worm can produce more than 200,000 eggs daily during its lifetime.

		Because of the massive number of eggs the gravid female produces, standard microscopic evaluation of stool smears is diagnostic. Prior to the production of ova, the presence of larvae in sputum samples or mature worms within feces or the oropharynx also is diagnostic.

		During the pulmonary stage, Ascariasis can produce mild fever, cough, and eosinophilia, with pulmonary infiltrates observable on plain chest radiographs (Loeffler's syndrome); the syndrome is usually mild and transient and produces no permanent lung damage.

 infection of the small bowel produces vague symptoms, which include nausea, vomiting, and colicky abdominal pain. Sometimes the adult worm can be visualized within the oropharynx or passing from the rectum. Moderate-to-large worm burdens can cause small bowel obstruction, volvulus, or intussusception. Additionally, migration of the worm into the biliary tract may lead to biliary colic, cholecystitis, cholangitis, intrahepatic abscess, and pancreatitis.

 ingest barium. Finding a central white line of barium within the worm's alimentary tract surrounded by a filling defect caused by the worm's body is diagnostic.

 Positive findings during longitudinal ultrasonography of the hepatobiliary tree demonstrate a hypoechoic, well-defined tube with echogenic walls and a central anechoic tube that corresponds to the worm's gastrointestinal tract. The worm may be seen as a "target sign" in the transverse plane. Additionally, a curling motion has been described on real-time ultrasonography.

 Ultrasonography of the fluid-filled small bowel demonstrates 

 worms that resemble "winding highways" or "parallel lines."

 Contrast-enhanced CT scanning may show the actual worm within the small bowel lumen, and the oral contrast within the worm's alimentary canal demonstrates the "target sign" (Figures).

Drs. Sutton and Pierce are military service members. This work was prepared as part of their official duties. Title 17 U.S.C. 105 provides that 'Copyright protection under this title is not available for any work of the United States Government.' Title 17 U.S.C. 101 defines a United States Government work as a work prepared by a military service member or employee of the United States Government as part of that person's official duties.

The views expressed in this article are those of the author(s) and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the United States Government.

			Khuroo MS. Ascariasis. Gastroenterol Clin North Am. 1996;25(3):553-577.

			de Silva NR, Chan MS, Bundy DA. Morbidity and mortality due to ascariasis: re-estimation and sensitivity analysis of global numbers at risk. Trop Med Int Health. 1997;2(6):519-528.

			Hotez P, deSilva N, Booker S, et al. Soil transmitted helminth infection: the nature, causes and burden of the conditions. DCPP Working Paper No. 3. Available at: 

			Shewmake R, Dillon B. Food poisoning: causes, remedies, and prevention. Postgrad Med. 1998;103(6):125-136.

			Erdog O, Sener H. The contamination of various fruits and vegetable with Enterobius vermicularis, Ascaris eggs, Entamoeba histolyca cyst and Giardia cysts. Food Control. 2006;12(6):557-560.

			Dwosh H, Hong H, Austgarden D, et al. Identification and containment of an outbreak of SARS in a community hospital. CMAJ. 2003;168(11):1415—1420.

			Division of Occupational Safety and Health Policy and Procedures Manual. Interim tuberculosis control enforcement guidelines. Available at: 

			Pecson B, Barrios J, Johnson D, et al. A real-time PCR method for quantifying viable Ascaris eggs using the first internally transcribed spacer region of ribosomal DNA. Appl Environ Microbiol. 2006;72(12):7864—7872.

			Centers for Disease Control and Prevention. Division of Parasitic Diseases. Parasitic disease information. Ascaris information. Available at: 

www.cdc.gov/ncidod/dpd/parasites/ascaris/moreinfo_ascaris.htm

			Mandell G, Bennett J, Raphael D. Mandell, Bennett, & Dolin: Principles and Practice of Infectious Diseases. 6th ed. New York, NY: Churchill Livingstone; 2005:chap 285.

			Branda JA, Lin TY, Rosenberg ES, et al. A rational approach to the stool ova and parasite examination. Clin Infect Dis. 2006;42(7):972-978.

			Cartwright C. Utility of multiple-stool-specimen ova and parasite examinations in a high-prevalence setting. J Clin Microbiol. 1999;37(8):2408-2411.

			Chitkara RK, Krishna G. Parasitic pulmonary eosinophilia. Semin Respir Crit Care Med. 2006;27(2):171-184.

			Danaci M, Belet U, Polat V, et al. MR imaging features of biliary ascariasis. AJR Am J Roentgenol. 1999;173(2):503.

			Alper F, Kantarci M, Bozkurt M, et al. Acute biliary obstruction caused by biliary acariasis in pregnancy: MR cholangiography findings. Clin Radiol. 2003;58(11):896-898.

			Rodriguez E, Gama M, Ornstein S, Anderson W. Ascariasis causing small bowel volvulus. Radiographics. 2003;23(5):1291-1293.

			Reeder MM. The radiological and ultrasound evaluation of ascariasis of the gastrointestinal, biliary, and respiratory tracts. Semin Roentgenol. 1998;33(1):57-78.

			Schulman A, Loxton AJ, Heydenrych JJ, et al. Sonographic diagnosis of biliary ascariasis. AJR Am J Roentgenol. 1982;139(3):485-489.

			Mahmood T, Mansoor N, Quraishy S, et al. Ultrasonographic appearance of Ascaris lumbricoides in the small bowel. J Ultrasound Med. 2001;20(3):269-274.

Articles

Surgical Rounds

What is causing the small bowel filling defect?

Close wounds quickly with an external tissue expander—

Wound Care Technologies has released DermaClose? RC, a continuous external tissue expander. DermaClose RC facilities the closure of moderate-to-large wounds quickly. It employs continuous radial tension to gently and quickly make adjacent tissue available for closure of full-thickness wounds up to 15 cm in diameter. Surgical stainless steel skin anchors are placed approximately 1.5 cm from the edge of the wound and penetrate the skin into the subcutaneous tissue. Each anchor is then stapled twice with a standard skin stapler, which comes with the DermaClose RC kit. The nylon suture line from the DermaClose RC tension controller is attached around each skin anchor, and the knob is rotated until a clutch mechanism provides an audible indication when full tension is achieved. Due to the constant force design, no additional tightening is required. When the wound edges are brought close together, the wound is ready for closure.

	DermaClose RC minimizes the need to undermine wound margins, decreasing chances of tissue death. It has been shown to reduce the length of scars significantly when compared with other closure techniques. This single-patient-use device provides health care professionals with greater flexibility to address moderate-to-large acute and chronic wounds.

Laparoscopic surgery and high-definition endoscopy require accurate and reliable video images. Barco now offers the MDSC-2124, a 24", 2-megapixel color display that incorporates the latest LCD technology. The MDSC-2124 delivers bright and crisp pictures in HD, providing surgical teams with detailed, artifact-free images, while meeting patient safety standards and the space requirements of the OR. The display's wide 24" screen has a native resolution of 1,920 x 1,200 pixels for viewing patient information, pathology images, and endoscopic video with pinpoint precision. Also available is the MDSC-1119, a 19" 1.3-megapixel LCD display. The MDSC-1119 features a high-contrast ratio, high color depth, and a wide viewing angle, to maximize image accuracy.

Fixed-wire and wire-guided balloon dilators—

Boston Scientific's CRE? Fixed Wire Balloon Dilator is designed to give surgeons the ability to achieve three distinct diameters at three separate pressures during in vivo dilation. Its rounded shoulders facilitate visualization of strictures while dilating. The high-pressure balloon produces little or no balloon waisting and is engineered for rapid deflation. The CRE Wireguided Balloon Dilator includes the same features as the Fixed Wire Balloon with the addition of a preloaded guidewire, designed to facilitate placement within tight strictures and tortuous anatomy. It may also reduce procedure time. Some experts have concluded that using a guidewire is a much safer and easier option for accurately passing the catheter through the anastomosis following a Roux-en-Y procedure and prior to inflation of the balloon for dilation when the anastomosis measures less than 5 mm.

Cartridge-based device assists in building brachytherapy seed trains—

The QuickLink? Delivery System, from Bard Urological, Inc, is a cartridge-based device that is designed to help physicians assemble brachytherapy seeds, spacers, and SourceLink? Connectors into seed trains of variable lengths and with variable seed-to-seed spacing. When treating prostate cancer with brachytherapy, time is critical, accuracy is paramount, and correct dosimetry is essential. The QuickLink system makes building custom seed trains quick, simple, and safe. It delivers the benefits of a connected implant with the advantages of real-time planning. The QuickLink delivery system is simple and intuitive for efficient loading, it creates custom needle loads with variable spacing, and it allows easy verification of seed and link configurations. The QuickLink delivery system is designed to be used solely with SourceLink Connectors.

Guide catheter facilitates directed laser ablation—

Spectranetics Corporation's TURBO-Booster functions as a guiding catheter used to treat arterial stenoses and occlusions in the leg. It facilitates the directed laser ablation of blockages in infrainguinal arteries at or above the knee. When combined with Spectranetics' TURBO elite laser catheter, the two are highly effective at treating lesions composed of calcium, thrombus, or fibrotic tissue. Together, they remove large amounts of plaque, create larger lumens, efficiently treat long, diffuse disease, and effectively target both eccentric and concentric lesions in the superficial femoral artery and popliteal arteries.

 does not endorse any products. All claims made are those of the manufacturers. For more detailed information, refer to package inserts or contact the firm.

 Close wounds quickly with an external tissue expander

	For those looking to sell their homes and retire in another state, Bottomline magazine recommends five locations based on their strong medical facilities, great culture, and reasonable home prices. In no particular order, the list includes 

, which has a median home price of $200,000, sunshine 310 days a year, and features a revitalized downtown, with upscale shopping and cafes. 

, also made the list. This community, with its diverse economy, has a median home price of $200,000, and cultural activities and attractions abound. 

, a town with a mild climate and old-fashioned Southern charm, is also highly rated. The affordable median home price is $160,000, and the town has strong literary underpinnings. 

, is also on the list, and, contrary to what you might expect, the landscape is green?not sunbaked. Austin has a great live music scene, excellent medical facilities, and a low median home price of $175,500. Finally, for those who can brave cold winters, 

, features great natural beauty, a median home price of $216,000, and excellent shops, restaurants, theaters, and medical facilities.

	• Filing small claims can have big repercussions

	Filing too many claims with your insurance company, regardless of how small, could result in your insurance carrier dropping you. The negative repercussions of being dropped by an insurance carrier could resonate for as long as 5 years, and you may find yourself unable to secure a new policy. 

 reveals that insurance companies share claims information with one another through the Comprehensive Loss Underwriting Exchange database, which tracks your claim history for 5 years. Claims cost insurers a bundle in administrative expenses, which is why even a small one sometimes leads to a cancellation notice. Companies are especially wary of water-related claims, because they could suggest additional damage in the future and indicate poor home maintenance. 

 recommends that if damages total just a few hundred dollars more than your deductible, it may be less expensive and cause less long-term grief to cover your own repair costs. Also, increasing your deductible to at least $1,000 can reduce premiums by as much as 25%, while simultaneously discouraging you from filing small claims.

	Preferred stocks are an investment vehicle that may make sense for surgeons who want a relatively stable place to park their money in an uncertain market. Like common stocks, preferred stocks represent partial ownership in a company, but dividends are paid to preferred stockholders before they are paid to common stockholders, and preferred stocks take precedence over common stocks in the event of liquidation. These securities trade like regular stocks and pay income like bonds, but they offer higher yields than bonds of comparable qualities. Purchased mainly by long-term investors, preferred stocks' big benefit is their 15% maximum dividend tax versus the 35% maximum tax on conventional bonds. 

 advises that before buying, you determine whether the stock is cumulative, in which case the company must make good on missed dividends, versus noncumulative, which has no such requirement. For additional information on how to evaluate preferred stocks, visit 

?Cumulative profits of the 10 largest US credit-card issuers in 2005. (

?Percentage of fewer collisions occurring in Las Vegas during the 8 months following teen-driving restrictions in 2006. (

?Percentage of households expecting to receive a pension. (

?Percentage of consumers concerned about not having enough money for retirement. (Experian-Gallup Personal Credit Index Survey, 2007)

?Percentage of consumers who worry about not being able to maintain the standard of living they currently enjoy. (Experian-Gallup Personal Credit Index Survey, 2007)

?Percentage of nonretired American adults who expect to lessen the extravagance of their lifestyle in retirement. (

?Percentage of workers (or their spouses) who have employer-provided defined benefit plans.(AARP, 2007)

?Average annual cost, including tuition, room, and board, of a four-year public college. (College Board, 2007)

?Average annual cost, including tuition, room, and board, of a private institution. (College Board, 2007)

?Total US consumer credit (revolving and nonrevolving). (

?Estimated number of songs illegally downloaded or exchanged in 2005. (

	A survey by the National Center for Women and Retirement Research (NCWRR) found that only one in four women respondents considered saving and investing for retirement a top priority. In 

 (ESP Press; 2006), author Jennifer S. Wilkov, CFP? combats this scary statistic by designing a practical system to help women get in touch with their financial situation. Taking a fun approach to money, Wilkov compares financial planning to a romantic relationship, breaking money matters down like a session in couples' therapy. Wilkov outlines eight steps, broken down by chapter, to creating a positive relationship with money: Building a Relationship; Making a Commitment to Manage Your Cash; Keeping a Commitment; Communicating and Connecting with Your Money; Organizing Your Money, Dating Your Money; Take a Money Time-out; and Embracing Change. The book includes practical tips, exercises, and a Money Mood Meter to keep in your wallet or checkbook. The Money Mood Meter is a tool for determining whether that impulse purchase is really needed or if it's an emotional response to an outside influence, eg, you're angry at your husband. 

 asks readers to examine their history with money, offers ideas on changing their approach to money, and guides them in keeping their relationship with money healthy and prosperous. Additional information on the book can be found at 

	If you use e-mail, it is likely you have received an unsolicited message ostensibly from a Nigerian official who needs your financial help to move large sums of money out of Africa. This is known officially as the ?Nigerian 419? scam, after a section of the Nigerian criminal code that addresses Internet fraud. In the past 10 years, thousands of people collectively have lost millions of dollars to 419-type scams. These 419 scams trap people from all walks of life and with all degrees of financial savvy. Apparently, greed or a penchant for risk-taking inhibits the brain's circuitry for rational thought. The FBI warns people not to reply to any e-mail from Nigeria that asks for personal or banking information or to place large sums of money in overseas bank accounts. Anyone you know who is contemplating or involved in such a transaction should be encouraged to contact the FBI or Secret Service immediately. For more information, visit the University of Pennsylvania's 419-scam information page at 

www.upenn.edu/computing/security/advisories/419scam.html

Bulletin Board topics cover filing small insurance claims, preferred stocks, email fraud, and more.

Surgeon's bulletin board

Have tumor burdens that correlate with serum levels of alkaline phosphatase

Most commonly arise in the humerus and radius

		The consistent finding in patients with primary hyperparathyroidism is		

Elevated serum levels of intact para?thyroid hormone

Elevated serum levels of alkaline phosphatase

		The cytokine that is made by T lymphocytes is		

Granulocyte-macrophage colony stimulating factor

		The most reliable measurement for diagnosing malnutrition is a		

Ratio of exchangeable sodium (Na) to exchangeable potassium (K) of 0.9

Respiratory quotient on indirect ca?l?orimetry of 1.0

Daily calorie intake that meets < 40% of total energy needs

		The best technique for avoiding post?operative deep vein thrombosis is		

Perioperative low-molecular-weight heparin

		Indications for repair of renovascular hypertension include all of the following EXCEPT		

Failure to respond to angiotensin-converting enzyme inhibitors

Increasing requirement for antihypertensive medication

Are generally polymicrobial in acute cholecystitis cases

Are less likely with increasing patient age

Increase in frequency in the presence of choledocholithiasis

Can readily be sterilized with antibiotics

Are less frequent in patients with biliary tract malignancies

Occurs most commonly in the second and third decades of life

Are at increased risk of developing a second breast primary

Increases in frequency with advancing age

Is not increased by corticosteroid therapy

Can occur in the absence of gastroesophageal reflux disease

Occurs in 25% of patients with ulcerative esophagitis

Regresses with proton-pump?inhibitor therapy

		Primary nonfunction of hepatic transplants		

Rarely occurs, even if the cold ischemia time is 24 hours

Alkaline phosphatase levels have been found to correlate well with tumor burden and survival. These lesions are half as common as osteogenic sarcomas and usually present with pain, tenderness, and a mass. The mainstay of treatment is radiation therapy and chemotherapy (doxirubicin, cyclophosphamide, vincristine, ifosfamide, etc). Surgery is reserved for control of local disease. Ewing?s tumors generally arise in the femur or pelvis.

None of these findings occur in all patients with primary hyperparathyroidism, and none are necessary for making the diagnosis. Elevated serum parathyroid hormone levels are very common but are not diagnostic in the absence of coexistent hypercalcemia. Half of patients with primary hyperparathyroidism have low serum phosphate levels, but levels rise in those with concurrent renal disease. Hyperchloremic metabolic acidosis oc??curs in 10% to 40% of patients. The serum alkaline phosphatase is elevated in only those patients with bone disease (< 5%).

The T lymphocyte product, granulocyte-macrophage colony stimulating factor, enhances bone marrow production of granulocytes. Tumor necrosis factor is synthesized by macrophages and monocytes, and its function is described by its title. Interleukin 11 is made by neurons and fibroblasts and increases platelet function. Erythropoietin is made by the kidneys to enhance red blood cell production. Interferon beta, a fibroblast product, increases the expression of class I major histocompatibility complexes.

Inadequate daily intake to meet energy expenditure needs is the most reliable means of documenting malabsorption. Since the circulating half-life of albumin is 14 to 18 days, a low level of this protein is nonspecific. The ratio of exchangeable Na to exchangeable K must exceed 1.2 to diagnose malabsorption. A respiratory quotient of 1.0 represents pure carbohydrate utilization. To be diagnostic of malabsorption, the respiratory quotient must be 0.7 or lower. Malnutrition is diagnosed if the patient has lost more than 10% of his or her body weight.

Early mobilization after operation is the best prophylaxis against deep vein thrombosis. While low-molecular-weight heparin and sequential compression devices decrease the occurence rate of deep vein thrombosis, neither is as effective as early mobilization. There are no data that passive ankle flexion or compressive stockings have any effect on the occurence rate of deep vein thrombosis.

While repair of a totally occluded renal artery might be performed occasionally, this procedure is contraindicated if the kidney is less than 6-cm in size. The remaining manifestations do call for surgical repair.

In the presence of concomitant choledocholithiasis, gallbladder bile is infected in 60% of patients. This percentage is significantly higher in the presence of cholangitis. Biliary tract cultures are rarely polymicrobial, except in cases of cholangitis. Postive bile cultures are more likely with increasing age and biliary tract malignancies. Unfotunately, it is almost impossible to sterilize the gallbladder with antibiotics.

The teens and early twenties are the most common ages for appendicitis, not childhood, as is often discussed. Eighty-five percent of appendicitis cases can be treated successfully with antibiotics, but the disease recurs in 35%. The most common cause of appendicitis is lymphoid hyperplasia. The mortality rate of 7% is correct in the elderly (octagenarians and older), but it is 1% to 2% in younger adults. Leukocytosis occurs in 60% of patients with acute appendicitis, and almost half of the patients with that disease are operated upon with normal white blood cell counts.

With no therapy other than excision, patients with these lesions have a 98% expected disease-free survival rate. No additional therapy is advantageous. Tumors that are 2.1 cm in diameter are T2 lesions. The risk of a second primary is the same in these patients as in the general population.

While never as high as 6%, rates of dehiscence increase with advancing age. Dehiscence is most commonly due to technical errors, and its frequency increases with corticosteroid use. Wound infections facilitate the development of dehiscence by causing tissue necrosis along the wound-closure margins.

Short-segment Barrett's esophagus occurs in 2% to 8% of people who do not have reflux esophagitis. The condition is three times more common in men and induces malignancy in 30% of patients afflicted with the metaplastic disorder. Barrett's esophagus occurs in 10% of patients with ulcerative esophagitis, and although proton-pump-inhibitor therapy stabilizes the disorder so that it does not progress, the abnormality does not regress or disappear.

Anhepatic patients cannot survive for very long, and there are few successful bridges to transplantation. Consequently, primary nonfunction is an emergency. Primary nonfunction is uncommon, occurring after 2% of liver transplants. The cause is usually related to donor factors. Preservation goals are 12 hours, and 24 hours is far beyond the ideal time frame. Primary nonfunction is rarely an immunologic complication, and it can be distinguished from hyperacute rejection.

Questions 

 Hepatic artery aneurysms (HAAs) are rare lesions of the splanchnic vasculature. These aneurysms have been linked to collagen vascular disorders, arteritis, and infection. The presentation of HAAs may be confusing because of the effects of biliary tree obstruction or bleeding.

 This paper reports a unique case of an HAA presenting as acute ascending cholangitis and highlights the unusual presentation of abdominal pain and obstructive jaundice caused by an HAA. This case demonstrates an association between methamphetamine use and acute aortic dissection, the combination of which likely served as a unique catalyst in forming the HAA.

 HAAs should be considered in the differential diagnosis of any patient presenting with cholangitis and extrinsic biliary compression, especially when risk factors for aortic dissection are present.

	Visceral artery aneurysms (VAAs) are extremely rare, with only small series and a few case reports published in the English-language literature.

 Their prevalence has been reported to be 1%, and postmortem examinations have shown an incidence between 0.098% and 10%.

 Hepatic artery aneurysms (HAAs) make up almost 20% of VAAs and are the second most common VAA, following splenic artery aneurysms (60%).

 Up to 22% of patients with VAAs present with rupture, and the reported mortality rate is between 8.5% and 21%.

	The classic triad of abdominal pain, jaundice, and gastrointestinal hemorrhage occurs in about one third of patients who present with an HAA. The incidence of these aneurysms has been rising over the last several years, most likely because of greater awareness, improved imaging techniques, and an increase in blunt and penetrating abdominal trauma cases.

	The etiologies of HAAs are diverse, with most reports citing preexisting atherosclerosis as a precipitating factor. Other causes include vasculitis (primarily associated with polyarteritis nodosa and systemic lupus) and iatrogenic injury to the hepatic artery leading to the formation of pseudoaneurysms.

 Welling and associates cited two cases of splanchnic artery aneurysms developing in patients who had a history of chronic methamphetamine use.

 We report the case of a 57-year-old man with a history of methamphetamine abuse, who developed an HAA secondary to an aortic dissection and presented to our facility with acute cholangitis.

	A 57-year-old Hispanic man with a history of chronic methamphetamine abuse presented to the emergency department with a several-day history of painless jaundice. The general surgical service evaluated the patient and recommended admission for further workup. The patient refused to be admitted and was discharged from the hospital, but he returned 3 days later, exhibiting right upper quadrant abdominal pain, fever, and jaundice. Laboratory tests were significant for a white blood cell count of 19,000/µL (normal, 4,500 to 10,000/µL), total bilirubin of 23 µmol/L (normal, 5 to 21 µmol/L), and direct bilirubin of 14 µmol/L (normal, < 3.4 µmol/L). A presumptive diagnosis of ascending cholangitis was made, and the patient was started on intravenous antibiotics.

	Endoscopic retrograde cholangiopancreatography (ERCP) demonstrated ex?ternal compression of the common bile duct (Figure 1). A common bile duct stent was placed, and a presumptive diagnosis of a Klatskin tumor was made. Cytology evaluations, however, were negative for malignancy. A computed tomography (CT) scan of the abdomen revealed a Stanford type-B aortic dissection with a 2.5-cm HAA compressing the common bile duct (Figure 2). Magnetic resonance angiography confirmed these findings (Figure 3).

	The patient underwent selective celiac angiography, which revealed an HAA that filled almost exclusively from the false lumen of the aortic dissection (Figure 4, below right). The patient was also noted to have a 1-cm splenic artery aneurysm and a 1-cm superior mesenteric artery aneurysm. Endoluminal treatment was not possible because the HAA arose from the false lumen of the aorta and could not be accessed. Open surgical treatment was undertaken. At celiotomy, the gallbladder was found to be distended, and cholecystectomy was performed. The HAA in?volved the common hepatic artery, and there was extensive inflammation in the portal triad. The aneurysm was controlled, opened, and ligated proximally and distally. There was no sign of hepatic ischemia, and hepatic revascularization was not performed.

	The patient had an uncomplicated postoperative recovery and demonstrated no signs of hepatic failure, sepsis, or recurrent jaundice. At the time of discharge, his bilirubin was normal, he tolerated a regular diet, and he had good pain control.

	VAAs are rare lesions that pose a significant challenge to the vascular surgeon. The first reported case of an HAA was by Quinke in 1871.

 Approximately 20% of all VAAs are aneurysms of the hepatic artery. The etiology for HAAs is diverse, but in most reported cases these an?eurysms are associated with bacterial endocarditis. Because of the availability of better treatment modalities, the incidence of mycotic visceral aneurysms has decreased, and most aneurysms are as?sociated with atherosclerosis. Other etiologies include vasculitides, trauma, and iatrogenic causes.

	The natural progression of a VAA is enlargement and eventual rupture, which results in a high mortality rate.

 Historically, up to 70% of these aneurysms have presented with rupture. Increased awareness of these aneurysms and improved imaging techniques have led to earlier diagnosis and treatment.

 In a 2003 report of 36 patients presenting with HAAs, only 14% presented with rupture, while 75% were asymptomatic at the time of diagnosis.

 Although it is difficult to predict which aneurysms will rupture, larger size and nonatherosclerotic etiologies (such as vasculitis, pancreatitis, peptic ulcer disease, autoimmune disease, or infection) are risk factors.

 While there have been only a few reported cases of patients presenting with obstructive jaundice, our case suggests that the presence of cholangitis should lead physicians to consider whether an HAA is present.

	Potential treatments for HAAs include endovascular and open techniques. There has been some controversy regarding when it is appropriate to manage these aneurysms expectantly. Most authors advocate treatment of any HAA larger than 2 cm, although there is no randomized, prospective data that fully support this approach.

 Endovascular techniques include coil embolization of the aneurysm, usually avoiding total occlusion of the artery.

 There have been reports of embolization failing due to migration of coils, abscess formation, and recanalization.

 The mortality rate cited for endovascular procedures has ranged from 0% to 43%.

 There has been at least one report of successful treatment of a ruptured hepatic pseudo?aneurysm using a coronary stent graft.

 Reber and associates suggest that coil embolization is the treatment of choice in high-risk patients with extrahepatic pseudoaneurysms.

 Standard open techniques include aneurysm ligation or repair with interposition grafting. Ligation is generally safe in cases where there is no significant preexisting hepatic dysfunction or portal hypertension, and this procedure avoids placement of a graft in an inflamed area that is often difficult to access.

	Although Welling and associates re?ported two cases of multiple VAAs developing in patients with a history of methamphetamine abuse,

 our case is unique for two reasons. First, we think our patient's condition resulted from a hypertensive crisis secondary to his methamphetamine abuse, which led to the formation of the HAA. Second, it is likely that his splenic and superior mesenteric artery aneurysms also resulted from his methamphetamine abuse, due to the gradual weakening of the arterial walls, a condition also reported by Welling and associates.

 The separate contributions of our patient's methamphetamine abuse and his aortic dissection in the genesis of the HAA are impossible to discern.

	Although cholangitis typically is at?tributed to intrinsic biliary pathology, including impacted choledocholithiasis and malignancy, physicians should be cognizant of other etiologies. HAA is a rare cause of obstructive jaundice, and HAAs are associated with high rates of morbidity and mortality due to rupture and exsanguination when they are not diagnosed and treated appropriately. Preoperative identification of an HAA as a cause of obstructive jaundice is important for successfully managing this condition.

		Abbas MA, Fowl RJ, Stone WM, et al. Hepatic artery an?eurysm: factors that predict complications. 

		Carr SC, Pearce WH, Vogelzang RL, et al. Current management of visceral artery aneurysms. 

		Hossain A, Reis ED, Dave SP, et al. Visceral artery aneurysms: experience in a tertiary-care center. 

		Messina LM, Shanley CJ. Visceral artery aneurysms. 

		Venturini M, Angeli E, Salvioni M, et al. Hemorrhage from a right hepatic artery pseudoaneurysm: endovascular treatment with a coronary stent-graft. 

		Welling TH, Williams DM, Stanley JC. Excessive oral amphetamine use as a possible cause of renal and splanchnic arterial aneurysms: a report of two cases. 

		Griffith JF, Bera SK, Loft DE. A case of obstructive jaundice. 

		Reber PU, Baer HU, Patel AG, et al. Superselective microcoil embolization: treatment of choice in high-risk patients with extrahepatic pseudoaneurysms of the hepatic arteries. 

		Kasirajan K, Greenberg RK, Clair D, et al. Endovascular management of visceral artery aneurysm. 

Jason Chiriano, Vascular Surgery Resident, Division of Vascular Surgery, 

Acute cholangitis secondary to a hepatic artery aneurysm and acute aortic dissection

 Percutaneous transthoracic fine-needle aspiration (FNA) biopsy is a relatively safe procedure that is commonly used to evaluate bronchogenic masses. A rare risk is implantation of malignant cells along the needle tract with subsequent tumor dissemination or chest wall implantation.

 This paper describes a case where malignant cells were implanted in the patient's chest wall as a result of percutaneous FNA of a primary lung carcinoma. The risks of FNA are discussed, and criteria for its use are suggested.

 The risk of seeding the tract by FNA should be avoided in patients with potentially curative lung lesions, and a more direct surgical approach may be indicated.

	Percutaneous transthoracic fine-needle aspiration (FNA) biopsy is a well-established technique for cytologic evaluation of bronchogenic masses. Although relatively safe, risks include pneumothorax, hemorrhage, air embolus, and hemoptysis. Implantation of malignant cells along the needle tract with subsequent tumor dissemination or chest wall implantation occurs rarely, and only a few such cases have been reported in the literature. We report a case of malignant cells being implanted in the chest wall as a result of percutaneous FNA of a primary lung carcinoma, highlighting the potential of tumor dissemination. We discuss the risks of FNA and suggest criteria for its use.

	A previously healthy 46-year-old African American woman presented to the emergency department with an asthma exacerbation. A chest radiograph showed an incidental mass of the left lung. A computed tomography (CT) scan was performed, which revealed a 3 x 2-cm spiculated mass in the left upper lobe of the lung. There were enlarged lymph nodes in the anterior mediastinum and subcarinal regions. A positron emission tomography scan showed intense uptake within the primary mass, two lymph nodes in the aortopulmonary window, and one node in the precarinal region. There was no evidence of distant metastasis. A CT-guided percutaneous FNA was performed using a 21-gauge needle (Figure 1). The cytology report revealed malignant cells characteristic of non-small cell carcinoma. The patient was started on neoadjuvant chemotherapy and radiation. After the treatment was completed, a left wedge resection with sampling of mediastinal lymph nodes was performed without complications. The tumor did not extend to the pleura. The histology confirmed a non-small cell carcinoma (Figure 2).

	Seven months later, the patient underwent a mammogram, which showed a mass in the left breast that was not present on her last mammogram. A CT scan revealed a left breast mass extending from the subcutaneous tissue through the deep pectoralis muscle down to the chest wall (Figure 3). A biopsy was performed. Surgical pathology revealed a moderately differentiated adenocarcinoma consistent with metastatic lung carcinoma (Figure 4).

	Although first described in 1883, percutaneous needle biopsy was not used regularly until the 1940s.

 Since that time, FNA has gained acceptance as a reliable diagnostic tool for lung masses. The obvious benefits of FNA are its simplicity, high diagnostic yield, infrequency of infection, and low morbidity rates.

 FNA has been performed in countless patients with relatively few complications. A critical risk factor, first recognized by Oschner and DeBakey in 1942, was the possibility of needle tract implantation and subsequent metastasis.

 Fortunately, implantation of neoplastic cells resulting in a secondary tumor is an uncommon complication.

	Experimental animal studies have shown that needle tract malignant dissemination is relatively common.

 These models state that up to 90% of needle tracts contain malignant cells but carry only a small risk of seeding a macroscopic metastatic tumor.

 In contrast, most human series report a clinical incidence of needle tract metastasis of less than 1%.

 There were several reported cases of needle tract implantation in earlier literature, especially in the 1980s. Nearly all of these occurred with the use of a larger bore Vim-Silverman cutting needle.

 There have been few reported cases of implantation or metastasis with the use of small bore needles.

	The specimen received from FNA is usually suitable for cytologic evaluation, but it is not necessarily accurate for determining cell type or tumor origin.

 Another important issue is that of sampling, and a negative aspirate does not absolutely exclude the diagnosis of cancer. The false-negative rate of FNA has been reported to be between 5% and 10%.

 Lillington compared the results of immediate thoracostomy with initial needle biopsy in the management of solitary lung nodules and found that thoracostomy provided better overall survival rates when the probability of the mass being malignant was high (>70%).

	Metastatic seeding along the needle tract likely has been underreported. Many patients die before adequate follow-up can be performed after FNA biopsy of a lung mass.

 In cases where needle tract metastases occur, patients with initially resectable carcinomas may develop unresectable lesions and be converted to an unfavorable prognosis.

	Although the development of needle tract metastases following FNA is rare, the consequences of this sequela are critical. The CT images and pathology results in our patient document this clearly. Each patient must be evaluated carefully. If the patient is a good operative candidate and has a primary lung carcinoma that is resectable by all clinical criteria, surgical intervention might be warranted without preoperative biopsy. The risk of seeding the tract, resulting in local implantation, should be avoided in patients with a potentially curable lung mass.

		Seyfer AE, Walsh DS, Graeber GM, et al. Chest wall implantation of lung cancer after thin-needle aspiration biopsy. 

		Voravud N, Shin DM, Dekmezian RH, et al. Implantation metastasis of carcinoma after percutaneous fine-needle aspiration biopsy. 

		Oschner A, DeBakey M. Significance of metastasis of primary carcinoma of the lungs: report of two cases with unusual site of metastasis. 

		Dick R, Heard BE, Hinson KF, et al. Aspiration needle biopsy of thoracic lesions: an assessment of 227 biopsies. 

		Sinner WN, Zajicek J. Implantation metastasis after percutaneous transthoracic needle aspiration biopsy. 

		Aronovitch M, Chartier J, Kahana M, et al. Needle biopsy as an aid to the precise diagnosis of intrathoracic disease. 

Lance K. Burns, Surgical Resident, Department of Surgery, Tulane University School of Medicine, New Orleans, LA; Bassam Abi-Rachad, Attending Surgeon, Department of Surgery, Rapides Medical Center, Alexandria, LA; Bernard M. Jaffe, Professor of Surgery, Department of Surgery, Tulane University School of Medicine, New Orleans, LA 

September 2007

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