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995

Letters ..

Ultrasound I wish

of Gallbladder

Wall

Invalid

our experience in reference to the article by Bergman et al. [1 ], and also to briefly describe an important ultrasonic distinction that can be made in the examination of the gallbladder wall. Bergman et al. described the ultrasonic findings in pericholecystic abscesses in three surgically proven cases. Within the last year, we had several similar patients who proved to have pericholecystic abscesses at surgery. Six patients demonstrated a well defined band

to relate

of low

level

echoes

around

also

demonstrated

a small

that

was

walled-off

by omentum.

hypoechoic

mass

defined

the

abscess

with

of the

the above An

above

ultrasound

important

We did

not

a case

and and

can

be

now

gallbladder

advanced form of have become quite

will

operate

compatible

made

of these

of a poorly

indistinct

a more clinically at our institution

findings

one

to the gallbladder

have

an

findings,

distinction

and

anterior

surrounding

outline, which is undoubtedly the same entity. The surgeons appreciative

gallbladder,

cavity

on patients

clinical

between

histories.

the

rim surrounded

using

high

or not

the

to the

high

by high

frequency rim

(5

MHz)

of anechoic

amplitude

echoes

a periocholecystic

or serosal

primarily

affecting

the

pretation

cannot

present, the ultrasound versus a mural process. important ulation

and examined

reliable has

and

is located

process in every

can

versus

wall

itself.

clinical

peripherally. by

noting

internally

a statement

gallbladder made

echoes

transducers

echoes,

be

amplitude

distinction. small,

However, further

REFERENCE

By

Snow JH Jr. Goldstein HM, Wallace 5: Comparison of scintigraphy, sonography, and computed tomography in the evaluation of hepatic neoplasms. AJR 132:915-918, 1979

1.

disease

Obviously,

this

however,

the

interwhen

patient

Reply In reply

pop-

of this finding

agree

Veterans

Administration

J. Handler Hospital

Long Beach, CA 90822

by

setting

history

and

our

HL, Kraut

B: Ultrasonographic evaluation of pericholecystic abscesses. AJR 1 32 : 201 -203, 1979 2. HandIer SJ: Ultrasound of gallbladder wall thickening and its relation to cholecystitis. AJR 1 32 : 581 -585, 1979

that

we

some

by

performed

We

concerning

fulfill

under

physical

and

was that

the

of

the

was same

conditions.

a specialized that

considerations

we

that

the

However,

the

and we are all biased

findings.

The

of

reader

sequence

physicians;

undoubtedly group

article,

criteria

by the referring

for the occasional

within feel

laboratory

used

our

scientific

#{149} #{149} blind

analysis

accounting

bias.

Franken

not

does not favor such conditions

analysis work

Dr.

does

prospective

unbiased,

AB, Neiman

letter

article

the examination retrospective

REFERENCES Bergman

this be

clinical

fore,

1 .

to the

that

analyses

is needed.

Stephen

University of Medicine IN 46202

regarding

inflammatory

since

School Indianapolis,

or externally

confirmation

are invalid.

Indiana

picture affords delineation of a serosal So far, we have found this to represent an been

the study, their conclusions

In Subjects and Methods, the authors state that the general sequence in which the three procedures were ordered was scintigraphy, followed by sonography and CT. They further state that . . prior knowledge of other test results was available in many cases This indicates that the analyses were not performed under blind conditions, and observer bias was encouraged rather than eliminated. If a comparison study is not properly designed and controlled, the resulting bias invalidates the results and conclusions. I believe this article does not fulfill the scientific criteria for valid interpretation, and I am disappointed that AJR saw fit to publish it. E. A. Franken, Jr.

whether

be made

case;

I interpret

gallbladder

wall and a pericholecystic inflammatory process. The normal gallbladder wall appears as a thin rim of medium light gray tone echoes within a rim of high amplitude echoes, as previously described [2]. When an abnormal gallbladder wall is identified, it appears as an anechoic

Conclusions?

This letter concerns the article by Snow et al. [1] in the June 1 979 AJR. On the basis of their study, the authors conclude that CT is the superior method for demonstrating hepatic neoplasms. As

biased. patients error.

institution

also

were

candidly

of

thereHowever,

was The

in fact

mere

fact

contributes

to

presented

the article. Despite

the

drawbacks

indicated

by Dr.

Franken,

we

still

believe

in

996

our

LETTERS

conclusions

are

retrospective

as valid

as possible

did

significantly

analysis

not

in any

clinical

influence

study.The

the

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University M.

of Texas

D. Anderson

System

Hospital

and

M. Goldstein

Wallace

Cancer

Center

Tumor

may

a violation

attention differ

somewhat

publication

contributors. from

our

policy

Although own,

AJR

should

be brought

European

policy

authors

of

the

attention

duplication, to the

it

seems

stated

in

appropriate

to

call

the

violation. Frederic University

N. Silverman Medical

Stanford,

CA

pulmonary

C, Worms vein

letter

The

we give special

countries

the

prevailing

of useful

their

usual

did

domain.

not

understand

are

of the AJR

language

consideration

is English.

to manuscripts

is not

observations

shall

not

readers

native

to

about

in part:

you

language

report

manuscripts

and

whose

For this reason,

outside

authors

instance

case

states,

that

Possibly

Americans

be aware

of the

to them

states

elsewhere.

English

and

Although

important

your

from

in order

that

develop-

paper

described

only one patient, it was on this basis that it was accepted. We will continue to welcome manuscripts from you and other non-American authors, and we shall continue to expect them to advise us of the originality

of the

material

they

offer.”

MMF

Vanishing

Diverticula

of the

Stomach

I offer another view of the intraluminal gastric diverticula of Tan that were invisible at endoscopy and not demonstrable on a control gastrointestinal study several months later. To be direct, I do

94305

were

not

think

due

they

were

AM, Luceri

in a child.

2. Pernot C, Hoeffel JC, Worms Ia veine pulmonaire commune.

AJR

AM, Hofmann Ann

Radiol

R: Persistence 133:121-122,

of the

times

fluid

1979

image

A: Persistance de 20 : 691 -693, 1977

viscous tence

and

diverticula

to artifacts in the

liquid; of high

at all.

In my opinion,

by the barium

(1 ) I had a similar

endoscopy

in vitro

created

the

jet in high

images

viscosity

stomach.

My arguments:

common

My

policy

where

this republication authors

the

for Authors

North

residual

JC, Pernot

for bringing

instructed

policies.

publication

Center

REFERENCES Hoeffel

1979

[1 ]

Stanford

1.

publication

ments

standards

is clearly

I have

predominantly

the Guidelines to Authors. I refer specifically to a case report in the July 1 979 AJR [1 ]. If the case report is compared to a previous report in another journal [2], the only apparent difference is the use of French in the original report. If the republication was deliberate and with your knowledge, this need not become a #{149} cause celebre. ‘ However, if you had no knowledge

our

readers

of your

of your

attention.

this

77030

Disclosed

I believe to the

Dr. Silverman

my

. . Our Guidelines have been published

Institute TX

November

Note

I thank

Snow

Sidney

Houston,

Duplication

Editors

results.

Judson Harvey

AJR:133,

was

by

pouring

(3)

Tan’s

viscosity

observation

negative

each

a high

density

figures residual

1 A and fluid;

Fig.

time;

(fig.

the

barium

suspension

in a

1 B clearly

show

(4)

a 1 963

study

1 -Vanishing

gastric

ula. Each time, endoscopy Images

1 ) several

I reproduced

and

(2)

due

jet in residual

to artifact

viscous

the

exis-

came

divertic-

was negative.

caused

by barium

gastric

fluid.

to

AJR:133,

November

the same conclusion diverticula

1979

I did about

the origin

of these vanishing

gastric

[2].

Paul Beeckman St.-Andriesziekenhuis B-8880

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997

LETTERS

Tielt,

Belgium

any credible explanation merits discussion However, I must disagree with his conclusion for the following reasons: 1 . In his films, the barium jet descending in high viscosity residual fluid within the stomach leaves a trail much like the tail of a comet. This finding was absent in my films.

2. The barium REFERENCES

Tan KM: 461-462, 2. Borgstrom 1.

untersuching

Intraluminal diverticula of the stomach. AJR 132: 1979 KE: Em Bariumkontrastph#{224}nomen bei der R#{246}ntgendes Magens. Radiologe 3 : 384-385, 1963

I do not deny

Professor diverticulum

he shows

lacks

the thin surrounding

that phenomena

such as Professor

describes occur. Like him, I have observed them not as dramatically. I thank him for his comments.

Reply

collection

collection

radiolucent line that is indicative of an intraluminal diverticulum and has been described in esophageal and duodenal intraluminal diverticula. It was quite clear in my illustrations. 3. My patient was upright for several minutes while several projections were obtained and I was puzzling over the finding. It showed no significant change in shape nor did it descend as an intraluminal barium jet would.

Beeckman of

barium In the

suggests described

absence

an alternate by

me

of positive

as

an

explanation

for the

intraluminal

gastric

pathologic

confirmation,

Permanente

Beeckman

occasionally,

but

Kong-Meng Tan Medical Group

Richmond,

CA

94804