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Finally, we should comment on the initial management

in Tanzania. Dentures of this size and shape in the pharynx
or upper oesophagus can usually be removed with forceps
through a rigid endoscope under general anaesthesia,
especially soon after the incident. Attempts to railroad an
upper aerodigestive tract foreign body are not generally
advisable, because of the high risk of viscus perforation and
subsequent infection9.

Acknowledgments We thank Mr A A Moir and Mr T

j| ~Fioure 3 The Alun-Jones for permission to report this patient under their
I' denture joint care and Mr A Narula for reading the manuscript.

possibility of abscess needs to be excluded early. Such REFERENCES

abscesses are potentially lethal because the retropharyngeal I Goldenberg D, Golz A, Joachims HZ. Retropharyngeal abscess: a
space is contiguous with the superior and posterior clinical review. J Laryngol Otol 1 997; 1 1 1:546-50
mediastinum. As well as mediastinitis, abscess rupture can 2 Neumann JL, Schlueter DP. Retropharyngeal abscess as the presenting
result in severe pneumonia. In this patient we also needed feature of tuberculosis of the cervical spine. Am Rev Respir Dis
1974;1 10:508-11
to exclude tuberculosis of the cervical spine, which can 3 Neal SL, Kearn MJ, Seeling JM, Harris JP. Manifestations of Pott's
present with a retropharyngeal mass2A, but the absence of disease in the head and neck. Laryngoscope 1986;96:494-7
bony erosion on the lateral neck X-ray made this diagnosis 4 Al Soub H. Retropharyngeal abscess associated with tuberculosis of the
unlikely. The presence of plasma cell infiltration in the cervical spine. Tuberc Lung Dis 1996;77:563-5
histological specimen was another distraction, but such 5 Singh B, Kantu M, Har-El G, Lucente FE. Complications associated
infiltrates can be secondary to chronic inflammation. with 327 foreign bodies of the pharynx, larynx, and oesophagus. Ann
Otol Rhinol Laryngol 1998;106:301-4
Extramedullary plasmacytoma, which is rare below the 6 Youngs RP, Gatland D, Brookes J. Swallowed radiolucent dental
age of 40, typically presents as a soft-tissue mass in the prostheses: risk of extraluminal oesophageal perforation. J Laryngol Otol
upper respiratory tract5; retropharyngeal plasmacytoma 1988;102:71-3
does not seem to have been reported. A case very similar to 7 Knowles JEA. Inhalation of dental plates hazards of radiolucent
materials. J Laryngol Otol 1991;105:681-2
this was reported in 1988 by Youngs and co-authors6; they,
8 Mucci B, Eyre T. Soft tissue neck radiography for displaced dental
and others subsequently78, called for incorporation of prostheses. Clin Radiol 1993;47:424-5
radio-opaque material to aid radiographic localization after 9 Rubin E, Farber JLF, eds. Pathology, 2nd edn. Philadelphia: Lippincott,
swallowing. 1988;1037, 1092

Ultrasound appearances in about the diagnosis ultrasound can be of valuel2. Despite

the frequency of acute appendicitis the concept of chronic
chronic appendicitis appendicitis as a cause of recurrent abdominal pain is
controversial. We report a case with sequential ultrasound
J M Wide MRCP FRCR G Lamont DM FRCR(Paed)l examinations.
A Boothroyd MBChB FRCR
J R Soc Med 1999;92:251-252
A 7-year-old boy was admitted after 24 hours of central
abdominal pain and vomiting. He had a slight headache and
sore throat but no alteration in bowel habit or urinary
Acute appendicitis is usually diagnosed on the basis of symptoms. There was a history of intermittent abdominal
physical signs and symptoms, but where there is doubt pain for which medical advice had not been sought. He was
apyrexial and examination revealed diffuse tenderness over
Departments of Radiology and Surgery', Royal Liverpool Children's NHS Trust, the lower abdomen. His white cell count was normal as was
Eaton Rd, Liverpool L12 2AP, UK urine analysis; he was thought to have either mesenteric
Correspondence to: Dr A Boothroyd, Consultant Radiologist adenitis or non-specific abdominal pain. Ultrasound of the 251

22wiffa2mme WHOMMM-11 -W W L'S -V -V - I -

Figure 3 The appendix wall (arrow) is now only mildly thickened

Figure 1 Ultrasound of the right iliac fossa: thickened, non-
compressible appendix with a thickened, echobright mesentery

from follow-up but returned to hospital five days later with

further abdominal pain. On examination the only finding
lower abdomen demonstrated free fluid in the right iliac was of localized pain in the right iliac fossa on deep
fossa around the caecal pole; a thickened, non-compressible palpation. At urgent operation a large but not acutely
appendix was identified arising from the caecal pole. The inflamed appendix was removed; no free fluid was present.
appendiceal mesentery was thick and echobright and On histological examination the serosal surface of the
contained several prominent vessels (Figure 1). Appearances appendix showed dilated and hyperaemic vessels and the
were felt to be consistent with an inflammatory process of lumen contained faecal material. There was diffuse fibrous
the appendix and mesentery. Despite these striking findings thickening of the appendix wall but no necrosis or
at ultrasound the patient improved over the subsequent 24 haemorrhage. The lamina propria was hyperplastic and
hours and was discharged. 48 hours later a further lymphoid tissue showed reactive non-specific hyperplasia.
ultrasound showed almost complete resolution of the free Postoperative recovery was uneventful and when seen a
fluid though the appendix remained inflamed and non- year later the boy had had no further pain.
compressible. The appendix was now surrounded by
echogenic material, presumed to be omental fat. No abscess
was detected (Figure 2). Four weeks later the only
abnormality seen on ultrasound was some thickening of Reports of chronic appendicitis are uncommon. Seidmen et
the appendix wall (Figure 3). The patient was discharged al. have described two cases of chronic appendiceal disease
though in only one case was ultrasound performed3. A
prospective study of 170 patients by Rioux4 demonstrated a
sensitivity of 93% in detecting acute appendicitis; and of 45
patients with proven appendicitis 5 had histological
evidence of a chronic inflammatory process with super-
imposed acute changes. Histologically, the chronic changes
consisted of replacement of submucosal fat by fibrous
tissue as observed in our patient. Of these 5 patients 4
were symptom-free shortly before surgery. Rioux also
described 4 further cases of 'false-positive' appendicitis
where ultrasound showed a non-compressible appendix but
because of rapid symptom resolution appendicectomy was
not performed. It was suggested that these cases might
represent subacute or chronic appendicitis. Our patient, we
believe, fits into this category. Falk et al. in a pathological
study of 47 cases, judged that a category of chronic
Figure 2 Appendix remains thickened and non-compressible but recurrent appendicitis is warranted on both histological and
252 the free fluid has resolved and appendix is now surrounded by fat immunohistological findingss. The major feature described

was fibrosis. 80% of cases showed a slight inflammatory cell REFERENCES

infiltrate whilst 60% showed activated lymphoid follicles 1 Sivet CJ, Newman KD, Boenning DA, et al. Appendicitis: usefulness of
with large germinal centres. In 28% lymphoid hyperplasia ultrasound in diagnosis in a pediatric population. Radiology
was recorded.
2 Siegel MJ. Acute appendicitis in childhood: the role of ultrasound.
Ultrasound has high sensitivity and specificity in the Radiology 1992;185:341-2
diagnosis of acute appendicitis, but false-positive and false- 3 Seidmen JD, Andersen DK, Ulrich S, et a]. Recurrent abdominal pain
negative results still occur and the decision to operate due to chronic appendiceal disease. South MedJ 1991;84:913-16
remains a clinical one. So far, there are few reported cases 4 Rioux M. Sonographic detection of the normal and abnormal appendix.
of chronic appendicitis, but the increased use of ultrasound AmJ Roentgenol 1991;158:773-8
may reveal that chronic or subacute appendicitis is more 5 Falk S, Schutze U, Guth H, et a]. Chronic recurrent appendicitis. A
clinicopathologic study of 47 cases. EurJ Pediatr Surg 1991;1:277-81
common than we had supposed.

Double pylorus as a cause of

gastrointestinal bleeding
Dirk Ehrhardt Matthias Lohr Stefan Liebe

J R Soc Med 1999;92:253-254

Figure 1 Endoscopic
MM appearance of gastric
outlet with view of
double pylorus
The most common causes of upper gastrointestinal tract
bleeding are peptic ulcer, haemorrhagic gastritis, oesopha-
geal varices, Mallory-Weiss syndrome, and tumours; ulcer was diagnosed and he was treated with intravenous
haemangiomas and bleeding from the biliary tract omeprazole 40 mg twice daily and intravenous amoxycillin
contribute a few casesl. For a double pylorus to present 100 mg three times daily. Within a few days the abdominal
in this way is very unusual. pain ceased entirely. At a second endoscopy there were no
signs of gastric bleeding, but in the prepyloric antrum the
entrance to a fistula was suspected (Figure 1). Double
CASE HISTORY pylorus was confirmed by side-view duodenoscopy,
A man aged 57 was admitted via the emergency room with cannulation and contrast radiography (Figure 2). Thence-
haematemesis and severe epigastric pain. He was an forth the patient's course was unremarkable, apart from
alcoholic and a smoker. 9 years previously a gastric ulcer development of gouty arthritis in the left foot which
had been diagnosed radiologically (but not endoscopically) responded to colchicine. He was discharged on day 14 and
and treated with H2-receptor antagonists; thereafter he had did not return for follow-up.
been free of abdominal pain until the present episode.
There had been no melaena.
On examination he was normotensive but anaemic COMMENT
(haemoglobin 7.9 g/dL, haematocrit 37%). Quick test was A duplicated gastric outlet is thought to arise in two ways.
76% normal, activated prothrombin time 28.7 s. At A congenital double pylorus is a rare anomaly caused by
endoscopy there was no blood in the stomach but clot gastric and duodenal duplication3'4. An acquired double
was seen adhering to the stomach wall in the prepyloric pylorus is a complication of prepyloric or postpyloric ulcer,
region. This could not be removed with forceps. Gastric which perforates the gastric and duodenal walls and gives
rise to a fistula. The prevalence in routine endoscopic and
Division of Gastroenterology, Klinik fur Innere Medizin, Universitat Rostock, radiodiagnostic procedures is estimated at between 0.02
Germany and 0.13%5, with a distinct overrepresentation of males6.
Correspondence to: Professor M Lohr, Division of Gastroenterology, The ulcers that give rise to these fistulas commonly show
Department of Intemal Medicine, University of Rostock, E. Heydemann Str. 6,
D-18055 Rostock, Germany themselves by bleeding, and there is often an underlying
E-mail: disease such as alcoholism, diabetes or chronic renal 253