Report Information from ProQuest22 December 2014 04:33_______________________________________________________________ 22 December 2014 ProQuestTable of contents1. Gastropericardial fistula complicating benign gastric ulcer: case report...................................................... 122 December 2014 ii ProQuestDocument 1 of 1 Gastropericardial fistula complicating benign gastric ulcer: case report Author: Zwirewich, Charles V; Simice, Peter ProQuest document link Full text: Submitted Feb. 1, 2000 Revision requested May 16, 2000 Resubmitted May 30, 2000 Accepted Jun. 5, 2000 A 75-year-old woman presented to the emergency department with acute central chest pain that was precededby a 3-week history of mild, diffuse chest discomfort and dysphagia for solids. She had undergone a partialesophagectomy and intrathoracic esophagogastric anastomosis for an in situ adenocarcinoma of thegastroesophageal junction 7 years prior. Postoperatively, the patient developed a chronic benign stricture at theanastomosis site that required intermittent dilatations. She had not undergone esophageal dilatation for severalmonths before the onset of her symptoms and there was no clinical evidence of tumour recurrence following theoriginal operation. On clinical examination, her blood pressure was 150/90 mm Hg; her heart rate was 105 beats per minute andrespiratory rate was 18. She was afebrile. A chest exam revealed scattered wheezes upon auscultation. Heartsounds were distant but normal, and jugular venous pressure was elevated. The patient exhibited mildepigastric tenderness but no guarding, rebound or masses on abdominal examination. Her serum electrolytes,leukocyte count and coagulation parameters were within the normal ranges. An electrocardiogramdemonstrated sinus rhythm, mild tachycardia and nonspecific ST-segment and T-wave changes.Anteroposterior and lateral chest radiographs were obtained (Fig. 1), and an upper gastrointestinal (GI) tractseries with a water-soluble contrast medium (Fig. 2) was performed. The chest radiographs showed gas within the pericardial sac. There was no pneumomediastinum orpneumothorax. The pulmonary vasculature was normal, and there was no evidence of pulmonary edema. Leftlower-lobe opacification and patchy right perihilar subsegmental atelectasis were present. A surgical staple linewas present to the left of the spine at T9-T11, and clips were present in the left upper quadrant and lower lefthemithorax. The upper GI tract series performed with water-soluble contrast medium demonstrated thatapproximately half of the stomach was located in an intrathoracic position. A 1.5-cm penetrating ulcer waspresent within the anterior wall of the stomach, approximately 5 cm below the surgical esophagogastricanastomosis. No mediastinal contrast extravasation or free communication between the pericardial sac and thegastric ulcer was demonstrated. The patient was diagnosed with pneumopericardium secondary to intrapericardial perforation of a benign gastriculcer and underwent an emergency left thoracotomy after intravenous antibiotic therapy was initiated. Theanterior surface of the stomach was adherent to the posterior surface of the pericardial sac. When this wastaken down, a 1-cm-diameter gastropericardial fistula was noted between a 1.5-cm benign gastric ulcer and thepericardial cavity. The pericardial sac was opened and found to be filled with purulent fluid. After it was irrigated,drains were placed into the pericardial sac and the supradiaphragmatic portion of the stomach and a portion ofthe intrathoracic esophagus were resected. The gastric remnant was stapled off, and the diaphragm wasclosed. A cutaneous esophageal mucous fistula was formed on the anterior chest wall to allow for the diversionof oral secretions, and a surgical jejunostomy tube was placed for nutritional support. Seven weeks later thepatient was readmitted for elective esophageal reconstruction using transverse colon, and she made anuncomplicated recovery. DISCUSSION 22 December 2014 Page 1 of 4 ProQuestPneumopericardium is a rare radiologic finding and is most commonly associated with esophageal ulceration ortrauma.(1)(2) Benign ulcers of the distal esophagus are the most frequent source of non-traumatic perforationinto the pericardial sac. Other etiologies include fistula formation from diseased subdiaphragmatic hollowviscera or subphrenic abscess, recent cardiac surgery, an extension of peumomediastinum into the pericardiumsac, and primary septic pericarditis from gasforming organisms.(1) Pneumopericardium caused by thepenetration of a benign gastric ulcer is a recognized but rare phenomenon.(2) Intrathoracic gastric perforationsare more commonly associated with pneumomediastinum. Risk factors associated with an increased risk ofpenetration of gastric ulcers into the pericardium include the presence of a giant ulcer in the gastric fundus, anulcer within a hiatus hernia, a history of hiatus hernia repair, concurrent use of non-steroidal anti-inflammatorydrugs (NSAIDs), and the Zollinger-Ellison syndrome.(1)(3) Scar-tissue formation at the site of previous hiatalsurgery may result in the adherence of the gastric fundus or lower esophagus to the pericardium, and produce apathway for benign ulcers to erode into the pericardium.(1) [Graph Not Transcribed] The intrathoracic gastric mobilization and esophagogastric anastomosis in this case resulted in the stomachlying close to the posterior wall of the pericardial sac, and presumably facilitated the penetration of the ulcer intothe pericardium. This complication of esophageal resection with gastric interposition is very rare, and we areaware of only 1 other reported case in the English literature.(4) The clinical signs and symptoms of esophageal or intrathoracic gastric perforation include dysphagia,odynophagia, tachycardia, cyanosis, hypotension and respiratory distress. Severe chest pain, exacerbated byswallowing or breathing, is a common feature. Symptoms of ulcer dyspepsia may be present. The clinicalfeatures of pneumopericardium are variable, and depend on the nature and acuity of the causative process.Acute onset of chest pain, with radiation to one or both shoulders, and dyspnea are common symptoms. Fever,shock and cyanosis are often present, and cardiac tamponade may be present in up to 37% of cases.(3)Suggestive clinical signs of pneumopericardium include: (1) a resonant percussion note over the precordiumwith shifting dullness, (2) a loud metallic splashing sound synchronous with the heart sounds at auscultation("succession splash," or Hamman's sign), and (3) a pericardial friction rub or "crunch" over thepericardium.(1)(5)(6) Radiologic findings in pneumopericardium are characteristic. A single band of gas is usually visible within thepericardial sac outlining the heart.(7) The band is curvilinear and often broad; if large enough, gas may outlinethe entire heart, producing the "halo sign."(7) The left pericardial margin may be distinctly visible as a discretesoft-tissue density band, outlined medially by gas in the pericardial cavity and laterally by the aerated left upperlobe. A pericardial air-fluid level may also be visible on the upright chest radiograph.(1)(5)(6) By contrast,pneumomediastinum usually manifests as a multitude of thin streaks of gas, which seldom surround the heartcompletely and which are rarely confined to the cardiac region only. Isolated pneumopericardium does notextend into the upper mediastinum and neck, a common finding in pneumomediastinum.(7) [Graph Not Transcribed] An upper GI tract series or esophagogram should be performed with water-soluble contrast media inhemodynamically stable patients in whom the cause of pneumopericardium is not readily apparent on clinicalgrounds. This will determine if the esophagus is abnormal, a hiatus hernia is present, and whether anesophageal or gastric fundal ulcer is present. The precise fistulous communication between the stomach oresophagus and the pericardial cavity can often be demonstrated in this way.(3)(6)(9) The contrast mediumshould be administered orally with the patient in the prone-oblique position. If the patient is unable to swallow oris too ill to lie prone, the study can be performed supine through a small-calibre feeding tube positioned in theupper esophagus via a trans-oral or trans-nasal approach. If perforation is suspected on clinical grounds but noobvious leakage is observed after administration of the water-soluble contrast medium, the study should bepromptly repeated with barium.(8) Computed tomography may be helpful in establishing the source of22 December 2014 Page 2 of 4 ProQuestpneumopericardium when the GI tract series is indeterminate.(2) Endoscopy should be avoided because airinsufflation during this procedure may enlarge the fistula and provoke cardiac tamponade.(9) Historically, the prognosis of pneumopericardium from a gastropericardial fistula has been grave. Before thedevelopment of modern antibiotics, gastropericardial fistulas were uniformly fatal.(5) Early diagnosis, surgicalintervention and the concurrent use of systemic antibiotics are now the cornerstones of management and offerthe best chance of survival.(1)(6) Chapman and Boals(2) recently reported successful non-operativemanagement of a patient with a transdiaphragmatic gastropericardial fistula from a benign giant gastric ulcer. The presence of pneumopericardium on a chest radiograph is a rare but ominous sign. Most patients will havelower esophageal perforation due to ulceration or trauma. Penetration of benign gastric ulcers into thepericardium is very rare but tends to occur when the ulcer is in the gastric fundus, in a hiatus hernia or inpatients with an intrathoracic stomach following esophagectomy. Radiologists should be aware that an upper GItract series performed with water-soluble contrast media is urgently required and is essential for pre-operativesurgical planning in these patients. REFERENCES (1) Edwards JRM, Humeniuk V. Gastropericardial fistula. Aust N Z J Surg 1996;66:257-9. (2) Chapman PR, Boals JR. Pneumopericardium caused by giant gastric ulcer. Am J Roentgenol1998;171:1669-70. (3) de Bruyne B, Dugernier T, Goncette L, Reynaert M, Otte JB, Col J. Hydropneumopericardium withtamponade as a late complication of surgical repair of hiatus hernia. Am Heart J 1987;114:444-6. (4) Romhilt DW, Alexander JW. Pneumopyopericardium secondary to perforation of benign gastric ulcer. JAMA1965;191:152-4. (5) Shackelford RT. Hydropneumopericardium. JAMA 1931;96:187-91. (6) Reisberg IR. Endoscopic antemortem diagnosis of gastropericardial fistula caused by perforation of benigngastric ulcer. Gastrointest Endosc 1974;21:27-9. (7) Bejvan SM, Godwin JD. Pneumomediastinum: old signs and new signs. Am J Roentgenol 1996;166:1041-8. (8) Ghahremani GG. Radiologic evaluation of suspected gastrointestinal perforations. Radiol Clin North Am1993;31:1219-34. (9) Schneider F, Schenk M, Tempe JD, Thiry L. Spontaneous gastropericardial fistula. Ann Emerg Med1995;26:394. Subject: Ulcers; Gastrointestinal diseases; Management; MeSH: Aged, Female, Fistula -- radiography, Gastric Fistula -- radiography, Heart Diseases -- radiography,Humans, Pericardium, Stomach Ulcer -- radiography, Fistula -- complications (major), Gastric Fistula --complications (major), Heart Diseases -- complications (major), Pneumopericardium -- etiology (major),Pneumopericardium -- radiography (major), Stomach Ulcer -- complications (major) Classification: 9172: Canada Publication title: Canadian Association of Radiologists Journal Volume: 51 Issue: 4 Pages: 244-7 Number of pages: 0 Publication year: 2000 Publication date: Aug 200022 December 2014 Page 3 of 4 ProQuestYear: 2000 Place of publication: Montreal Publication subject: Medical Sciences--Radiology And Nuclear Medicine ISSN: 08465371 Source type: Scholarly Journals Language of publication: English Document type: PERIODICAL Document feature: Illustrations; References Accession number: 10976245 ProQuest document ID: 236133776 Document URL: http://search.proquest.com/docview/236133776?accountid=25704 Copyright: Copyright Canadian Medical Association Aug 2000 Last updated: 2011-04-29 Database: ProQuest Research Library _______________________________________________________________ Contact ProQuest Copyright 2014 ProQuest LLC. All rights reserved. - Terms and Conditions 22 December 2014 Page 4 of 4 ProQuest

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Laporan dari ProQuest Informasi22 Desember 2014 04:33_______________________________________________________________22 Desember 2014 Protestan kina estTable isi1. Gastropericardial fistula rumit ulkus lambung jinak: Kasus ....................................... Laporan ............... 122 Desember 2014 ii ProQuestDocument 1 dari 1Fistula Gastropericardial rumit ulkus lambung jinak: Kasus LaporanPenulis: Zwirewich, Charles V; Simice, PeterLink dokumen ProQuestFull Text: Dikirim Februari 1, 2000Revisi meminta 16 Mei 2000Dikirimkan kembali 30 Mei 2000Diterima Juni 5, 2000Perempuan 75 Tahun berusia disampaikan kepada departemen darurat dengan nyeri dada akut yang tengah didahuluioleh sejarah 3 minggu ringan, difus ketidaknyamanan dada dan disfagia untuk padatan. Dia memiliki ndergone parsialesophagectomy dan intratoraks anastomosis esofagogastrik untuk in situ karsinoma kecil de darigastroesophageal junction 7 tahun sebelumnya. Pasca operasi, pasien mengembangkan striktur jinak kronis diSitus anastomosis yang diperlukan dilatations berselang. Dia memiliki ndergone Tidak dilatasi esofagus selama beberapaSebelum bulan timbulnya gejala dan ada sedikit tumor klinis Providence of currence menyusuloperasi yang asli.Pada pemeriksaan klinis, tekanan darah Cadangan nya 150/90 mm Hg; Denyut jantung nya 105 denyut per Menit danTingkat pernapasan adalah 18. Dia adalah seorang demam. Ujian dada mengungkapkan mengi tersebar pada auskultasi. hatiPELACUR tapi jauh terdengar normal, dan tekanan vena jugularis diangkat. Pasien dipamerkan ringankelembutan epigastrium tetapi sedikit penjagaan, Rebound atau massa pada pemeriksaan perut. Elektrolit serum nya,ukocyte hitungan dan koagulasi parameter PELACUR dalam rentang normal. elektrokardiogramirama sinus menunjukkan, setelah chycardia ringan dan tidak spesifik St-segmen dan T-gelombang perubahan.Anteroposterior dan toraks lateral radiografi diperoleh PELACUR (Gbr. 1), dan pencernaan bagian atas (GI) saluranseri dengan media kontras larut dalam air (Gambar. 2) dilakukan.Radiografi dada menunjukkan gas dalam kantung perikardial. Ada sedikit atau pneumomediastinumpneumothorax. The paru virus SCU lature normal, dan ada sedikit Takdir edema paru. kirirendah-lobus kekeruhan dan tambal sulam kanan perihilar subsegmental atelektasis PELACUR hadir. The bedah pokok Barishadir di sebelah kiri tulang belakang di T9-T11, dan klip PELACUR hadir dalam kuadran kiri atas dan bawah kirihemithorax. GI series saluran atas dilakukan dengan media kontras larut air menunjukkan bahwasekitar setengah dari perut terletak di posisi intratoraks. The 1.5-cm menembus ulkus adalahhadir dalam Dinding anterior perut, kira-kira 5 cm di bawah esofagogastrik bedahanastomosis. Tidak ada ekstravasasi kontras mediastinum atau komunikasi bebas Antara kantong pericardial danulkus lambung ditunjukkan.Pasien didiagnosis dengan pneumoperikardium Sekunder untuk intrapericardial perforasi lambung jinakmaag dan menjalani meninggalkan torakotomi Darurat Setelah terapi antibiotik intravena dimulai. itupermukaan anterior perut itu patuh pada permukaan posterior kantung perikardial. Ketika initurun diambil, 1-cm berdiameter fistula gastropericardial tercatat Antara 1,5 cm ulkus lambung jinak danrongga perikardial. Kantung perikardial dibuka dan ditemukan untuk diisi dengan cairan bernanah. Setelah itu irigasi,PELACUR saluran ditempatkan ke dalam kantong pericardial dan bagian supradiaphragmatic perut dan bagian dariyang PELACUR kerongkongan intratoraks direseksi. Sisa lambung dijepit off, dan diafragma adalahtertutup. The kulit fistula esophagus mukosa dibentuk di dinding dada anterior untuk memungkinkan pengalihansekresi oral, dan tabung jejunostomy bedah ditempatkan untuk dukungan nutrisi. Tujuh minggu kemudianPasien diterima kembali untuk rekonstruksi esofagus kolektif ini menggunakan usus besar melintang, dan ia membuatpemulihan tidak rumit.PEMBAHASAN22 Desember 2014 Halaman 1 dari 4 ProQuestPneumopericardium adalah temuan radiologis langka dan Apakah Terkait dengan Kebanyakan ulkus esofagus umum atautrauma. (1) (2) borok jinak esofagus distal adalah sumber daya paling sering perforasi non-traumatikke dalam kantung perikardial. Etiologi lainnya termasuk pembentukan fistula dari subdiaphragmatic berongga sakitjeroan atau abses subphrenic, operasi jantung Terbaru, sebuah PERPANJANGAN dari peumomediastinum ke perikardiumsac, dan septik utama perikarditis dari gasforming organisme. (1) yang disebabkan oleh pneumoperikardiumpenetrasi ulkus lambung jinak adalah diakui tetapi fenomena yang langka. (2) intratorasik perforasi lambunglebih sering Terkait dengan pneumomediastinum. Faktor risiko Terkait dengan peningkatan risikopenetrasi ulkus lambung ke dalam perikardium termasuk adanya ulkus raksasa di fundus lambung, sebuahulkus dalam hernia hiatus, sejarah perbaikan hernia hiatus, penggunaan bersamaan non-steroid anti-inflamasiobat (NSAID), dan Sindrom Zollinger-Ellison. (1) (3) pembentukan Scar-jaringan di lokasi hiatus sebelumnyamungkin Hasil dalam operasi dari dherence dari fundus lambung atau esofagus lebih rendah untuk pericardium, dan mereka menghasilkanjalur untuk ulkus jinak untuk mengikis ke perikardium. (1)[Grafik Tidak mediakan]Mobilisasi lambung intratoraks dan anastomosis esofagogastrik dalam hal ini mengakibatkan perutberbaring dekat dengan posterior Dinding kantung perikardial, dan mungkin difasilitasi penetrasi ulkus menjadiperikardium. Ini komplikasi reseksi esofagus dengan penempatan lambung Apakah sangat langka, dan dibacaHanya 1 sadar melaporkan kasus lain di Sastra Inggris di. (4)Tanda-tanda klinis dan gejala esofagus atau lambung perforasi intratoraks termasuk disfagia,phagia dyno, kami chycardia, sianosis, hipotensi, dan gangguan pernapasan. Nyeri dada yang parah, diperburuk olehmenelan atau bernapas, adalah panel ature umum. Gejala ulkus dispepsia Mungkin hadir. klinispneumoperikardium adalah fitur riable virus, dan tergantung pada alam dan ketajaman dari sative proses.Onset akut nyeri dada, dengan radiasi ke satu atau kedua bahu, dan dyspnea adalah gejala umum. Sakit Demam,sianosis dan syok sering hadir, dan setelah mponade jantung Mungkin hadir di ul menjadi 37% kasus. (3)Anda ggestive tanda-tanda klinis pneumoperikardium meliputi: (1) catatan perkusi resonan atas prekordiumdengan kebodohan pergeseran, (2) sebuah percikan logam keras terdengar sinkron dengan Hati auskultasi suara di("Splash suksesi," atau Hamman yang Masuk), dan (3) dari pericardial friction rub atau "krisis" di atasperikardium. (1) (5) (6)Temuan radiologis merupakan salah satu ciri pneumoperikardium. Band tunggal gas adalah biasanya terlihat dalamkantung perikardial menguraikan Hati (7) Band ini adalah lengkung dan sering luas.; cukup jika besar, gas Mei utlineseluruh Hati, menghasilkan "Halo Sign." (7) pericardial margin kiri Mungkin jelas terlihat sebagai diskritBand kepadatan jaringan lunak, diuraikan medial oleh gas dalam rongga perikardial dan lateral oleh kiri atas aerasilobus. Kadar cairan perikardial ber-Mungkin juga terlihat pada foto toraks tegak. (1) (5) (6) Sebaliknya,pneumomediastinum biasanya bermanifestasi sebagai di ltitude coretan tipis gas, yang jarang mengelilingi Hatibenar dan yang jarang terbatas pada jantung Hanya Region. Tidak terisolasi tidak pneumoperikardiummeluas ke mediastinum atas dan leher, umum ditemukan pada pneumomediastinum. (7)[Grafik Tidak mediakan]Sebuah GI atas saluran atau esophagogram seri harus dilakukan dengan kontras air-larut dalam Mediapasien hemodinamik stabil di antaranya penyebab pneumoperikardium Bukan mudah terlihat pada klinisalasan. Ini Akan de termine jika esofagus yang abnormal Apakah, Apakah hadiah hiatus hernia, dan apakahesofagus atau tukak lambung Apakah hadir fundus. Komunikasi fistulous tepat Antara perut atauesofagus dan rongga perikardial sering dapat ditunjukkan dalam cara ini. (3) (6) (9) Media kontrasharus diberikan secara oral dengan pasien dalam posisi rawan-blique tersebut. Jika pasien adalah tidak mampu menelan atauApakah terlalu sakit untuk berbohong rawan, Studi dapat dilakukan melalui Kecil kaliber tabung pengisi terlentang diposisikan diesofagus bagian atas melalui pendekatan trans-trans-oral atau hidung. Jika perforasi Apakah dicurigai pada Grounds klinis tapi kecilApakah akage jelas diamati Setelah pemberian media kontras larut dalam air, Studi harussegera diulang dengan barium. (8) Computed tomography Mungkin membantu dalam membangun sumber daya22 Desember 2014 Halaman 2 dari 4 ProQuestpneumopericardium ketika saluran pencernaan Apakah seri bawah rminate tersebut. (2) Endoskopi harus dihindari penyebab Air reproduksiinsuflasi selama cedure Protestan ini Mei memperbesar fistula dan memprovokasi jantung menjadi mponade. (9)Secara historis, prognosis pneumoperikardium gastropericardial dari fistula telah kuburan. sebelumpengembangan antibiotik modern, fistula gastropericardial pelacur seragam yang fatal (5) Diagnosis dini., bedahintervensi dan penggunaan bersamaan antibiotik sistemik merupakan landasan Sekarang dan menawarkan ManajemenPeluang terbaik untuk bertahan hidup. (1) (6) Chapman dan Boals (2) baru-baru ini melaporkan sukses non-KoperasiPengelolaan pasien dengan fistula gastropericardial transdiaphragmatic dari ulkus lambung jinak raksasa.Kehadiran pneumoperikardium pada foto toraks adalah jarang namun menyenangkan Sign. Kebanyakan pasien memiliki Willperforasi esofagus bagian bawah atau ulserasi akibat trauma. Penetrasi ulkus lambung jinak ke dalamApakah perikardium sangat jarang tetapi cenderung terjadi ketika ulkus Apakah dalam fundus lambung, dalam hernia hiatus ataupasien dengan perut intratoraks berikut esophagectomy. Ahli radiologi harus menyadari bahwa GI atasseri saluran dilakukan dengan kontras larut air Media Is Apakah sangat diperlukan dan penting bagi penatua-Koperasiperencanaan bedah pada pasien ini.REFERENSI(1) Edwards JRM, Humeniuk V. Gastropericardial fistula. Aust N Z J Surg 1996; 66: 257-9.(2) PR Chapman, JR Boals. Raksasa pneumoperikardium disebabkan oleh tukak lambung. Am J Roentgenol1998; 171: 1669-1670.(3) de Bruyne B, Dugernier T, L Goncette, Reynaert M, Otte JB, Kolonel J. Hydropneumopericardium denganSetelah mponade sebagai komplikasi akhir dari operasi perbaikan hernia hiatus. Am Hati J 1987; 114: 444-6.(4) Romhilt DW, Alexander disebut Siswa-Siswa Alkitab. Pneumopyopericardium sekunder perforasi ulkus lambung jinak. JAMA1965; 191: 152-4.(5) Shackelford RT. Hydropneumopericardium. JAMA 1931; 96: 187-91.(6) Reisberg IR. Diagnosis antemortem endoskopi fistula gastropericardial disebabkan oleh perforasi jinaktukak lambung. Gastrointest Endosc 1974; 21: 27-9.(7) Bejvan SM, JD Godwin. Pneumomediastinum: tanda-tanda tua dan tanda-tanda baru. Am J Roentgenol 1996; 166: 1041-8.(8) GG Gha hremani. Evaluasi radiologis dicurigai perforasi gastrointestinal. Radiol Clin Utara Am1993; 31: 1219-1234.(9) Schneider F, Schenk M, JD Tempe, L. Thiry gastropericardial fistula spontan. Ann Emerg Med1995; 26: 394.Perihal: Bisul; Penyakit pencernaan; manajemen;MESH: Aged, Female, Fistula - radiografi, Lambung Fistula - radiografi, Penyakit Jantung - radiografi,Manusia, perikardium, Perut Maag - radiografi, Fistula - komplikasi (Major), Lambung Fistula -komplikasi (Major), Penyakit Jantung - komplikasi (Major), pneumoperikardium - etiologi (Major),Pneumoperikardium - radiografi (Major), Perut Maag - komplikasi (Major)Klasifikasi: 9172: CanadaPublikasi Judul: Asosiasi Kanada Ahli Radiologi JournalVolume: 51Isu: 4Halaman: 244-7Jumlah halaman: 0Publikasi Tahun: 2000Tanggal publikasi: Agustus 200022 Desember 2014 Halaman 3 dari 4 ProQuestYear: 2000Tempat publikasi: MontrealSubjek publikasi: Ilmu Kedokteran - Radiologi dan Kedokteran NuklirISSN: 08465371Jenis sumber daya: Jurnal IlmiahBahasa publikasi: Bahasa InggrisJenis Dokumen: BERKALADokumen panel ature: Ilustrasi; ReferensiNomor Aksesi: 10976245ProQuest dokumen ID: 236133776Dokumen URL: http://search.proquest.com/docview/236133776?accountid=25704Hak Cipta: Hak Cipta Canadian Medical Association Agustus 2000Terakhir diperbarui: 2011/04/29Daniel tabase: ProQuest Perpustakaan Penelitian_______________________________________________________________ Hubungi ProQuestHak Cipta 2014 ProQuest LLC. All Rights reserved. - Syarat dan Ketentuan22 Desember 2014 Halaman 4 dari 4 ProQuest