Clin Radiol

Renal dysfunction in liver cirrhosis: renal duplex Doppler US vs. scintigraphy for early identification.

Al-Kareemy EA. Sobh MA. Muhammad AM. Mostafa MM. Saber RA.
Department of Internal Medicine, Faculty of Medicine, Assiut University, Egypt.
A diagnostic tool to detect early renal dysfunction before it becomes irreversible would be useful in cirrhosis. This study was carried out to evaluate the role of Doppler sonography and Tc-99m DTPA renography in the detection of early renal dysfunction in patients with different grades of liver cirrhosis. Renal arteries of 43 patients with cirrhosis and normal renal function tests were compared with 15 age and gender matched normal subjects as a control group using colour Doppler sonography and Tc-99m DTPA scintigraphy. The patients were categorized into three groups, A (14), B (14) and C (15), according to a modified Child's classification that assesses the severity of liver cirrhosis. Doppler results revealed a highly significant increase in both the pulsatility and resistive indices in groups B and C compared with either group A patients or control subjects and in group C compared with group B (P < 0.001) in the main renal arteries as well as in the interlobar and arcuate arteries. Insignificant differences were observed between group A and controls (PI: control 0.96+/-0.08, group A 0.95+/-0.07, group B 1.26+/-0.06, group C 1.48+/-0.06; RI: control 0.57+/-0.02, group A 0.58+/-0.02, group B 0.66+/-0.01, group C 0.72+/-0.02). Abnormal renograms in the form of delayed appearance (34+/-14.6 s), diminished blood flow bilaterally with prolonged secretory (12+/-4.5 min) and excretory phases (> 30 min) and poor response to intravenous frusemide were only observed in group C patients. Radionuclide computed glomerular filtration rate was within the normal range in patients of group A (81+/-9.5 ml/min) and group B (78+/-8.4 ml/min) and reduced only in patients of group C (34+/-14.5 ml/min). Thus Doppler sonography can detect an increase in renal vascular resistance in patients with moderately severe cirrhosis (Child grade B) when renography was normal. We conclude that Doppler sonography can be used for earlier identification of cirrhotic patients with a higher risk of impending renal failure earlier than renography and may also be used to guide therapeutic approaches.

Choledocholithiasis associated with malignant biliary obstruction--significance and management.

Nichols DM. Macleod AJ.
Department of Radiology, Raigmore Hospital, Inverness, UK.
Distal bile duct stones and proximal extra-hepatic malignant biliary obstructions may coexist. These stones, probably predating the development of the malignant obstruction but of unknown aetiological significance, were found in seven of 60 patients with proximal tumours (11.6%) at percutaneous biliary drainage. In two of these cases, stones blocked outflow from a supra-ampullary stent. All seven patients also had evidence of gall-bladder stones. Five of the seven patients had cholangiocarcinoma, giving an incidence of duct stones in such patients (n = 27) of 18.5%. In one case, the stones were removed endoscopically, in four, the stones were removed percutaneously and, in the remaining two cases, they were left in situ beside a stent. None of 120 cases with malignant obstruction had stones proximal to the obstruction. Distal common duct stones are associated with proximal malignant biliary duct obstruction, especially with cholangiocarcinoma and coexisting gall-bladder stones. They may interfere with stent function and cause diagnostic confusion at cholangiography.

Intussusception in adults: CT diagnosis.

Gayer G. Apter S. Hofmann C. Nass S. Amitai M. Zissin R. Hertz M.
Department of Diagnostic Imaging, The Chaim Sheba Medical Center, Tel Hashomer, Israel.
PURPOSE: Intussusception in adults is nowadays usually diagnosed on computed tomography (CT), as CT is often the first modality for the investigation of prolonged abdominal pain from which these patients suffer. We wish to present the CT, clinical and pathological findings of 16 adult patients with intussusception seen over a 5-year period. MATERIALS and METHODS: The abdominal scans of 16 patients with intussusception were reviewed. Special attention was directed to the location of the mass, its shape and fat content, possible underlying pathology and dilatation of the bowel proximally. The findings were correlated with clinical and pathological data. RESULTS: Eight men and eight women, aged 34-81 years, were studied. The most frequent indication for CT was prolonged abdominal pain. CT findings included an inhomogeneous soft tissue mass, target or sausage-shaped, depending on the angle of the CT beam vs. the intussusception, with a fatty component in 14 of the 16. Intussusception was enteroenteric (six), ileocolic (three), or colocolic (seven). Complete small bowel obstruction was present only in one case and some bowel dilatation in three. The underlying pathology could be diagnosed on CT in only two cases of lipoma. Nine patients had an underlying malignant process, eight of them unsuspected. Of the other five, two had coeliac disease, two were classified as idiopathic and one had a necrotic polyp of undetermined pathology. CONCLUSION: Intussusception on CT presented a characteristic mass lesion containing fat stripes in almost all patients. Obstruction was rarely seen. Malignant lesions were the most common cause and therefore early diagnosis and prompt intervention are essential.

Dynamic contrast-enhanced MR imaging of perianal fistulae.

Year 1998
Spencer JA. Ward J. Ambrose NS.
Department of Radiology, St. James's University Hospital, Leeds, UK.
We describe the normal magnetic resonance (MR) anatomy of the perianal region and relate this to the surgical anatomy of perianal fistulae. We illustrate the surgical classification of perianal fistulae and the range of complications of fistulous disease encountered in clinical practice.

Computed tomography compared with small bowel enema in clinically equivocal intestinal obstruction.

Year 1998
Makanjuola D.
Department of Radiology, College of Medicine and King Khalid University Hospital, King Saud University, Riyadh, Kingdom of Saudi Arabia.
OBJECTIVE: To compare the findings in computed tomography (CT) and small bowel enema (SBE) in clinically equivocal small bowel obstruction in order to identify the reasons for the limitation of CT evaluation. SUBJECT AND METHOD: Over a period of 5 years, 49 patients who had both CT and SBE within a period of 1 week were analysed. The findings at SBE were categorized into partial low-grade, partial high-grade and complete obstruction and compared with the CT findings. A critical analysis of the CT false-negative cases was made. The predictive values for the determination of the presence of obstruction in CT were also obtained. RESULTS: Forty-three out of the 49 patients had proven intestinal obstruction. CT correctly identified 34 cases including 19 of 20 with partial high-grade obstruction, two with complete obstruction and 13 out of 21 cases of partial low-grade obstruction. Among those cases with low-grade obstruction cases with complex or long segment narrowing or with masses were correctly identified while six patients with short stenotic segment due to various causes were not. CT also had two false-positive findings of obstruction in patients with mesenteric infarction. SBE had neither false positive nor false negative. The sensitivity, specificity, positive predictive value and negative predictive values for CT were 83%, 67%, 94% and 36%, respectively. Abrupt transition from dilated to collapsed loops in CT were caused by various intraluminal lesions apart from adhesions. CT was superior to SBE in showing extraluminal masses, revealing abscesses, tuberculous lesions and malignancy anterior adhesions as well as features of strangulation. CONCLUSION: Apart from degree of obstruction and the presence of masses, the length of the stenotic part also affected CT detection. Abrupt change from dilated to collapsed segment could be due to various transmural and intraluminal lesions although adhesions was the commonest lesion. While SBE is more accurate in identifying the presence and location of obstruction, CT is superior for detection of the cause of small bowel obstruction and also for the presence of strangulation. In places where CT is more widely used for intestinal obstruction, SBE evaluation could be prudently considered in CT negative cases of clinically equivocal intestinal obstruction.

Pictorial review: Radiological diagnosis of duodenal abnormalities.

Year 1998
Hwang JI. Chiang JH. Yu C. Cheng HC. Chang CY. Mueller PR.
Department of Radiology, Veterans General Hospital-Taipei and National Yang-Ming University, Taiwan, Republic of China.
This article depicts the radiological findings of many common gastrointestinal entities. Specifically, examples of disease processes that affect the stomach, gall bladder, small intestine, pancreas and colon are shown. In most cases there is correlation between ultrasound, computed tomography (CT) and fluoroscopic imaging. The major emphasis of the article, however, is to demonstrate classic barium imaging of a large number of gastrointestinal disease processes.

The role of hepatic arterial embolization in the treatment of spontaneous rupture of hepatocellular carcinoma.

Year 1998
Ngan H. Tso WK. Lai CL. Fan ST.
Department of Diagnostic Radiology, The University of Hong Kong, Queen Mary Hospital, Pokfulam.
Thirty-three patients presenting with spontaneous rupture of hepatocellular carcinomas (HCCs) were referred for emergency transcatheter arterial embolization. Blood was present in the ascitic fluid on abdominal paracentesis in all 33 patients. Seventeen patients underwent emergency computed tomography (CT). HCCs were demonstrated on CT in all 17 patients. Blood was detected in the peritoneal cavity or around the liver surface on CT in 15 patients (88.2%), one of whom also had active extravasation of the contrast medium into the peritoneal cavity. Vascular tumours were present in the hepatic angiograms prior to embolization in all 33 patients but extravasation of the contrast medium from the HCC was seen on angiography in only six patients (18.2%). Bleeding from the ruptured HCC was stopped at the end of the procedure in 32 patients who had undergone successful embolization. The overall median survival time was 9 weeks. The median survival time of patients with a serum total bilirubin level of 50 micromol/l or below was 15 weeks, while that of patients with a serum total bilirubin level above 50 micromol/l was only 1 week, the difference being statistically significant. Embolization is therefore the treatment of choice in arresting life-threatening bleeding in ruptured HCC in patients with a serum total bilirubin level of 50 micromol/l or below, but the procedure is rarely effective in prolonging survival in patients with a serum total bilirubin above this critical level.

The angiographic diagnosis of colonic carcinoma.

Year 1998
Ho S. Jackson J.
Department of Imaging, Imperial College of Science, Technology and Medicine, Hammersmith Hospital, London, UK.
Carcinoma of the colon is a common cause of chronic iron deficiency anaemia in elderly patients and is conventionally diagnosed by either barium enema or colonoscopy. Occasionally these studies are inconclusive and individuals may proceed to further imaging, including angiography. Between December 1991 and October 1996, 337 patients were referred for visceral angiography to determine the cause of chronic gastrointestinal bleeding. In seven of these individuals (two males and five females with an age range of 65-74 years), all of whom had been investigated by barium enema and colonoscopy, both reported as showing no cause for bleeding, an arteriographic diagnosis of colonic carcinoma was made. Four of these demonstrated patchy areas of increased vascularity whilst three were predominantly hypovascular. Early venous drainage was seen in five. Marked irregularity and truncation of vasa rectae was present in six; more subtle irregularity was visible in one. The mural veins were irregular with or without truncation in five of the six patients in whom they were visualized. The marginal artery was angiographically involved in only two cases and in one of these the tumour was irresectable. It is important to recognize that a previous 'normal' colonoscopy and barium enema does not exclude a colonic neoplasm, even if advanced, and that this diagnosis may be made angiographically. Confusion with other pathologies, such as angiodysplasia, should be prevented by close scrutiny of vasa rectae at the site of arteriographic abnormality, which will usually demonstrate vascular irregularity and truncation highly suggestive of malignancy.

Pyelocalyceal diverticula containing milk of calcium--CT diagnosis.

Year 1998
Gayer G. Apter S. Heyman Z. Morag B.
Department of Diagnostic Imaging, The Chaim Sheba Medical Center, Tel Hashomer, Israel.
OBJECTIVE: To present the computed tomography (CT) findings of pyelocalyceal diverticula containing milk of calcium in seven patients. MATERIAL AND METHODS: Three patients were examined because of flank pain, one because a malignant lesion was suspected and the three others were examined for unrelated symptoms. Three repeated scans to the kidney area were performed in every patient: an unenhanced scan, post-contrast scan and a delayed scan. RESULTS: Unenhanced scans demonstrated an intraparenchymal round lesion with calcific material localized either at the inferior border or filling almost the entire cavity. On post-contrast scans a contrast-fluid level appeared, with some enhancement of the clear fluid in the upper part of the cyst. A further rise in the contrast-fluid level or total opacification with a density identical to that of the collecting system was obtained on delayed scans. CONCLUSION: Pyelocalyceal diverticula containing milk of calcium present on CT as a partially calcified renal mass. Slight opacification soon after injection may be mistaken for enhancement arousing suspicion of a tumour. However, a delayed scan will demonstrate a densely opacified cyst filled with contrast from the collecting system which is virtually pathognomonic of the lesion.

Radiographic detection of achalasia: diagnostic accuracy of videofluoroscopy.

Year 1998
Schima W. Ryan JM. Harisinghani M. Schober E. Pokieser P. Denk DM. Stacher G.
Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, USA.
AIMS: To retrospectively evaluate the accuracy of videofluoroscopy in the diagnosis of achalasia. MATERIALS AND METHODS: Videofluoroscopic studies of the oesophagus of 53 patients (25 males, 28 females; mean age, 49 years) with manometrically revealed diagnosis of achalasia were retrospectively evaluated. The videofluoroscopic examinations had been carried out with one swallow of low-density barium suspension in the erect and up to three swallows in the prone oblique position. Videofluoroscopically, a diagnosis of achalasia was made in 31 of the patients (58%) with manometrically proven achalasia, of whom only nine had oesophageal dilatation. Non-specific oesophageal motor abnormalities were diagnosed radiographically in 18 patients (34%) and a normal motility in four patients (8%). CONCLUSION: Videofluoroscopy is a valuable and sensitive technique for the detection of disordered oesophageal motility in achalasia.

Self-expanding metal stents in the management of colorectal carcinoma--a preliminary report.

Year 1998
Wallis F. Campbell KL. Eremin O. Hussey JK.
Department of Diagnostic Imaging, Aberdeen Royal Infirmary, Foresterhill, UK.
AIMS: The role of diagnostic imaging in colorectal carcinoma is in the initial diagnosis, staging and detection of complications of the disease. Seven cases of colorectal carcinoma are presented where expandable metallic stents were placed for the management of stenosing lesions in patients with advanced metastatic disease or with serious medical complications which prevented immediate surgery. RESULTS: Seven patients (five male, two female) with an age range of 51-76 years had expandable metallic stents placed over a 9-month period. All stents were placed successfully with no immediate complications. The stents remained in situ for a range of 7-210 days. CONCLUSION: Expandable metallic stents can be successfully and safely placed in the colon. These stents may be useful in the management of patients with advanced metastatic disease or in those presenting with large bowel obstruction in which decompression by a stent allows treatment of coexisting medical complications to enable surgery to be carried out at a later date.

Carbon dioxide enhanced ultrasonography of hepatic haemangiomas.

Year 1998
Chen WT. Chen RC. Wang CK. Tu HY. Chiang LC. Chen PH.
Department of Radiology, Taipei Municipal Jen-Ai Hospital, Taiwan, Republic of China.
The purpose of this study was to characterize the imaging manifestations of carbon dioxide enhanced ultrasonography (CO2US) in hepatic haemangiomas. CO2US was performed for 52 haemangiomas in 25 patients and for 352 various hepatic nodules in 192 patients. Characteristic enhancement patterns for hepatic haemangiomas were noted. All 39 large haemangiomas (> 1 cm) demonstrated peripheral nodular enhancement in the early and parenchymal phases associated with delayed washout character (> 30 min). Centripetal fill-in of CO2 was noted in 82.1% of large haemangiomas. Two enhancing patterns were noted in 13 small haemangiomas (< 1 cm): peripheral nodular (69.2%) and homogeneous (30.8%). Delayed washout was also noted in all small haemangiomas. Centripetal fill-in of CO2 was hard to define in small haemangiomas. None of the other 352 hepatic nodules had the same imaging features. In conclusion we found that CO2US is valuable in differentiating hepatic haemangiomas from other liver tumours in clinically doubtful cases.

US findings of xanthogranulomatous cholecystitis.

Year 1998
Kim PN. Ha HK. Kim YH. Lee MG. Kim MH. Auh YH.
Department of Diagnostic Radiology, Asan Medical Center, University of Ulsan, Songpagu, Seoul, Korea.
The ultrasound (US) scans of eleven patients with histologically proven xanthogranulomatous cholecystitis have been reviewed. The thickness of the gallbladder (GB) wall, echogenicity of the thickened GB wall, the presence of intramural nodules, gallstones, pericholecystic fluid, loss of wall definition with the liver, and intrahepatic ductal dilatation were specifically assessed by two radiologists. The range of thickness of the GB wall was 3-20mm (mean, 11.2 mm). Thickening was diffuse in nine cases and focal in two. The thickened GB wall, excluding intramural nodules, was echogenic in seven, isoechoic in three and hypoechoic in one, compared with hepatic echogenicity. Intramural nodules were found in eight cases. These were discrete, oval or flat, and of low echogenicity. These ranged in size from 6 to 12 mm (mean, 10.5 mm). Gallstones were present in six cases and there was intrahepatic duct dilatation in two of these. Definition between the liver and the GB was obliterated in seven cases. One case of GB perforation, confirmed at operation, demonstrated pre-operatively a GB wall defect and connection with the surrounding pericholecystic fluid. Pericholecystic fluid was absent in the other 10 cases. Xanthogranulomatous cholecystitis presents ultrasonically as GB wall thickening, and the majority of cases in this series also demonstrated intramural hypoechoic nodules. These findings can be helpful in the diagnosis of xanthogranulomatous cholecystitis.