Correlation of perfusion abnormalities on CTAP and immediate postintravenous gadolinium-enhanced gradient echo MRI

Background: The purpose of this study was to evaluate patients with wedge-shaped perfusion defects seen on spiral CT arterial portography for the presence of transient increased wedge-shaped enhancement on dynamic gadolinium-enhanced gradient echo MR images. Methods: Nineteen patients underwent CTAP and MRI within a 2-week interval. All patients with wedge-shaped perfusion defects on CT arterial portography were evaluated in a separate review session for the presence of transient increased segmental hepatic enhancement on dynamic gadolinium-enhanced spoiled gradient echo (SGE) MR images. Results: Eight patients were identified to have subsegmental, segmental, or lobar wedge-shaped perfusion defects by CT arterial portography. In 8/8 patients, there was transient wedge-shaped increased hepatic enhancement on MR images which corresponded to the perfusion defects identified on CT arterial portography. Transient increased enhancement on MR images was observed on immediate postgadolinium images as high-signal intensity of the involved subsegment, segment, or lobe. This relatively high-signal area faded to near isointensity in all cases on images obtained at 45 s. Conclusion: Wedge-shaped perfusion defects demonstrated by CT arterial portography corresponded to wedge-shaped increased hepatic enhancement following gadolinium administration on SGE MR images. Received: 29 December 1994/Accepted: 7 February 1995     

Hepatocellular carcinoma with sarcomatous change: characteristic findings of two-phased incremental CT

Background: Because of its poor prognosis, the diagnosis of hepatocellular carcinoma with sarcomatous change (HCCSC) is clinically important. The purpose of this study is to elucidate the characteristic CT findings of HCCSC. Methods: Two-phased dynamic incremental CT images of six histologically proven HCCSC were retrospectively reviewed. Results: All tumors (100%) exhibited peripheral enhancement on delayed CT images. Lymphadenopathy was observed in 100% (six of six patients); intrahepatic metastases, in 83% (five of six). Both metastatic lesions showed findings similar to those of the primary hepatic tumors, such as peripheral enhancement. Histopathologically, delayed and/or prolonged peripherally enhanced areas consisted of viable cancer cells with sarcomatous changes. Conclusions: The appearance of HCCSC on CT is that of an irregularly demarcated intrahepatic mass with delayed or prolonged peripheral enhancement, frequently with intrahepatic metastases and lymphadenopathy. Received: 5 December 1994/Accepted: 4 January 1995     

Focal hepatic nodules after transcatheter oily chemoembolization; detection with spiral CT versus conventional CT

Background: The objective of this study was to determine if spiral computed tomography (CT) results in increased rate of detection of focal hepatic nodules containing iodized oil after transcatheter oily chemoembolization when compared with conventional CT. Methods: Spiral CT with single 24-s breath-hold technique was compared with conventional sequential CT in 42 patients with suspected hepatocellular carcinomas. Two sets of CT scans obtained after transcatheter oily chemoembolization were independently reviewed by two radiologists. The slice thickness was 10 mm for both data sets. The number and sizes of focal hepatic nodules containing iodized oil were documented. All 42 patients had at least one hepatic nodule. The lesion size varied from 2 mm to 12 cm. Results: In six of the 42 patients, more hepatic nodules could be identified on spiral CT compared with conventional CT. When scans with spiral CT were used, 107 nodules were detected, whereas 98 nodules were detected with conventional CT. Overall, nine (9%) more nodules were detected with spiral CT (<+>p= .002). If lesions larger than 2 cm are excluded, nine (15%) more lesions were detected with spiral CT (<+>p= .002). Conclusion: Spiral CT results in increased rate of detection of focal hepatic nodules after transcatheter oily chemoembolization, particularly in lesions smaller than 2 cm. Received: 11 October 1994/Accepted: 6 November 1994     

Spread of gallbladder carcinoma: CT evaluation with pathologic correlation

Background: To assess the accuracy of computed tomographic (CT) imaging in the detection of spread and staging of gallbladder carcinoma. Methods: CT findings of spread of gallbladder carcinoma in 59 Japanese patients who underwent radical surgery were correlated retrospectively with pathologic findings. Results: The incidence of histologically proven nodal involvement was 54% (32 patients) and the most common spread of gallbladder carcinoma. The sensitivities in CT detection of N1 and N2 nodal involvement were 36% and 47%, respectively; positive predictive values were 94% and 92%, respectively. Direct extension to the liver, extrahepatic bile duct, and gastrointestinal tract or pancreas were histologically confirmed in 24, 18, and five patients. The sensitivities in the CT detection of direct spread to the liver of less than 2 cm, more than 2 cm, the extrahepatic bile duct, and the gastrointestinal tract or pancreas were 65%, 100%, 50%, and 57%, respectively; positive predictive values were 77%, 100%, 90%, and 100%, respectively. The incidence of liver metastases and involvement of interaortocaval nodes were 7% and 16%, respectively. The sensitivities in CT detection of liver metastases and involvement of interaortocaval nodes were 75% and 21%, respectively; positive predictive values were 100% and 86%, respectively. CT could not detect direct spread to omentum and peritoneal seedings. Conclusion: For detecting the spread of gallbladder carcinoma, CT imaging has low to moderate sensitivity; however, CT imaging can help in determining resectability and in planning the treatment, especially in advanced-stage gallbladder carcinoma, because of a high positive predictive value. Received: 5 July 1995/Accepted: 8 August 1995     

Total proctocolectomy and ileoanal pouch: the role of contrast studies for evaluating postoperative leaks

Background: To assess the role of contrast enemas for the evaluation of leaks in symptomatic and asymptomatic patients after the first stage of restorative proctocolectomy. Methods: We reviewed the findings of 59 contrast enemas in 40 patients who underwent total proctocolectomy with creation of an ileoanal pouch and a proximal diverting ileostomy. Thirty-seven patients initially underwent routine contrast studies of the ileoanal pouch, and three underwent contrast studies because of suspected fistulas or obstruction. Medical records were also reviewed to determine the clinical presentation and course of these patients. Results: Of 37 patients who underwent routine postoperative contrast enemas, 33 (89%) had normal studies, three (8%) had clinically silent leaks (including two blind-ending tracks from the ileoanal anastomosis and one from the pouch), and one (3%) had pouchitis. In all three patients with unsuspected leaks, ileostomy closure was delayed. In two other patients with abdominal pain and fever, contrast enemas revealed leaks from the ileoanal pouch and distal ileum, respectively. The remaining patient had a contrast enema because of abdominal pain and distention; this patient had a distal ileal obstruction due to adhesions. Conclusions: Routine postoperative contrast studies revealed clinically silent leaks from the ileal J pouch or ileoanal anastomosis in three of 37 patients (8%) after the first stage of restorative proctocolectomy. Our findings suggest that routine contrast enema can detect clinically silent leaks after this surgery. Received: 31 January 1997/Accepted: 5 March 1997     

Radiographic findings of intractable gastric ulcers with H2-receptor antagonists

Background: To clarify the radiographic characteristics of intractable gastric ulcers with H₂-receptor antagonists. Methods: The radiographic findings at the time of starting treatment were compared between 42 patients with gastric ulcers that did not heal within eight weeks of starting treatment with H₂-receptor antagonists (the intractable group) and 58 patients whose ulcers healed within the eight-week period (the tractable group). Results: The following radiographic findings in the intractable group were observed at a significantly higher incidence than those in the tractable group and included: an ulcer located on the angle, linear ulcers, a greater depth, an uneven mound surrounding an ulcer, prominent folds' convergence, an overhanging gastric mucosa, an irregular ulcer base, a shortening of the lesser curvature and a U-shaped deformity of the angle. A multiple logistic regression analysis showed that the following three factors had a significant and independent delaying effect on healing: a U-shaped deformity of the angle, an uneven mound surrounding an ulcer and prominent folds' convergence. The relative risk of these factors were 12.7, 14.4 and 12.5, respectively. Conclusions: Intractable gastric ulcer with H₂-receptor antagonists can be predicted based on the characteristic radiographic findings at the start of treatment. Received: 23 December 1994/Accepted: 25 January 1995     

The frequency,appearance, and significance of splenic perfusion defects on CT arterial portography

Background: The purpose of this study was to determine the frequency, appearance, and significance of splenic perfusion defects on computed tomographic arterial portography (CTAP). Methods: CTAP was performed with dynamic scanning at 1-cm increments on 46 consecutive patients prior to laparotomy. Two readers retrospectively reviewed these studies in consensus and recorded the number, size, and shape of focal splenic perfusion defects. These defects were later correlated with surgical findings and at least one of the following imaging modalities: delayed CT 4<+>–<+>6 h after CTAP, intravenously enhanced CT, sonography, or magnetic resonance imaging (MRI). Results: Splenic perfusion defects were present in 14 of 46 CTAP studies (30%), and in seven patients these defects were multiple. Most defects were wedge-shaped and peripherally located, although several round defects simulating metastases were also present. The spleen was normal at surgery in all patients, and comparison imaging revealed only a small splenic infarct in one patient on MRI. Conclusions: Splenic perfusion defects occur in about one-third of patients referred for CTAP, are usually wedge-shaped but may be round, and should not be interpreted as metastases without other evidence of a space-occupying mass. Received: 11 October 1994/Accepted: 6 November 1994     

Spontaneous rectus sheath hematomas: clinical and radiological features

We reviewed the clinical and radiological features in eight patients with spontaneous rectus sheath hematoma (RSH). The diagnosis was confirmed at surgery in four patients, and spontaneous resolution occurred in the other four. All patients were elderly adults. Acute abdominal pain and a palpable mass after muscular strain, such as coughing or twisting, were features highly suggestive of RSH. Sonographically, these hematomas may be confused with abdominal wall tumors. On CT scans, a hyperdense mass posterior to the rectus abdominis muscle with ipsilateral anterolateral muscular enlargement is considered characteristic of acute RSH, although chronic RSH may be isodense or hypodense relative to the surrounding muscle. MRI is very useful in the diagnosis of RSH, which is demonstrated as a high signal intensity area on both T1- and T2-weighted images, especially when the CT findings are not specific for RSH. Received: 16 August 1994/Accepted: 3 October 1994     

Current status of small bowel radiography

Background: In the past, small bowel examinations were usually ordered for the sake of ``completeness.' As a result, small bowel radiography was performed casually and without attention to detail. This review examines pertinent clinical issues and the recent contribution of small bowel radiography to the evaluation and management of the patient with suspected small bowel disease. Recommendations for the clinical utilization of small bowel radiography are discussed. Methods: Analysis of pertinent citations addressing valid indications for, and technique of, small bowel radiography from 1980 to July 1995 through a computerized bibliographic search (Medline and Current Contents). Results: Accepted clinical indications for small bowel radiography include (1) unexplained gastrointestinal bleeding, (2) possible small bowel tumor, (3) small bowel obstruction, (4) Crohn disease, and (5) malabsorption. The current literature reflects the limitations of the conventional small bowel follow-through, various modifications to improve its clinical yield, the important contribution of enteroclysis in the workup, and subsequent management of patients with possible small bowel disease. A controversy in the radiology literature exists as to whether to use the small bowel follow-through or enteroclysis as the primary method of examining the small bowel. Conclusion: The thoughtful selection of patients by clinicians for small bowel radiography is essential to make radiologic evaluation cost effective. The incidence of disease of the small intestine is low and is associated with nonspecific symptoms. Because of the inherent difficulty of visualizing numerous loops of an actively peristalsing bowel, a reliable imaging method is needed that not only detects small or early structural abnormality but also accurately documents normalcy. The yield of information provided by enteroclysis and its high negative predictive value suggests that it should be the primary method for small bowel examination. The ``overhead'-based conventional small bowel follow-through should be abandoned. The ``fluoroscopy'-based small bowel follow-through augmented when necessary by the peroral pneumocolon or the gas-enhanced double-contrast follow-through method is an acceptable alternative when enteroclysis is not possible. Received: 0/0/00Accepted: 0/0/00     

Large lipomas of the colon: CT and MR findings in three symptomatic cases

We report on three patients with large lipomas in the wall of the cecum, causing intussusception. Endoscopy is the preferred modality for small lipomas, whereas CT and MR imaging are more useful in their ability in detecting fatty masses and assessing the location of lesions. Barium enema study may contribute to the preoperative planning in selected cases. Received: 1 November 1994/Accepted after revision: 5 January 1995     

Suprapubic versus transrectal ultrasonography in assessing the volume of the prostate and the transition zone in patients with benign prostatic hyperplasia

The reliability of suprapubic ultrasonography (SU) in assessing the size of the prostate was examined in 95 patients with benign prostatic hyperplasia (BPH). Volumetric measurements of the prostate and the transition zone of the prostate (TZP) performed by SU were compared with corresponding measurements obtained by transrectal ultrasonography (TU). A very strong correlation was found between suprapubically and transrectally performed measurements for both the total prostate gland (r= 0.948, p < 0.001) and the TZP volume (r= 0.953, p < 0.001). According to the results of this study, SU appears to be as reliable as TU in assessing the size of the prostate and the TZP and may be used effectively in the evaluation of patients with BPH, as it is less cumbersome, better tolerated, and a widely available examination technique. Received: 21 October 1994/Accepted after revision: 12 December 1994     

Color Doppler imaging of the gallbladder wall in acute cholecystitis: sonographic<+>–<+>pathologic correlation

Background: The purpose of this study was to evaluate the usefulness of color Doppler imaging (CDI) in suspected cases of acute cholecystitis. Methods: Twenty-two patients suspected of having acute cholecystitis were prospectively evaluated over a 12-month period using gray-scale and color Doppler technique. Gallbladder wall thickness was greater than 2 mm in all patients included in the study. Pathologic correlation was obtained in 17 patients, with clinical or sonographic follow-up in five for a period of 6<+>–/011001/months. CDI was considered positive only if the mid to fundal wall demonstrated flow. Sonographic Murphy's sign and laboratory values were recorded. Results: Eight patients had acute cholecystitis. All had positive color Doppler flow. Wall thickness in these patients ranged between 4 and 10 mm. Three patients with necrotizing acute cholecystitis had no flow within 6<+>–<+>8-mm walls. Six patients with pathologically proven chronic cholecystitis had no evidence of increased flow within thickened walls. Five patients with presumed chronic cholecystitis (thickened wall without increased color flow) were treated medically, and their symptoms resolved. CDI was more sensitive in predicting acute cholecystitis than was the sonographic Murphy's sign and/or laboratory values. Conclusion: CDI demonstrates hyperemic changes in thickened gallbladder walls and is an important adjunct in the diagnosis of acute cholecystitis. Received: 3 February 1995/Accepted: 24 March 1995     

Significance of the computed tomography finding of subcapsular hepatic necrosis in liver transplantation

Background: To evaluate the clinical significance of the computed tomographic finding of subcapsular hepatic necrosis following liver transplantation. Methods: 105 computed tomography scans performed in 50 allografts, 6 days to 4 years following transplantation, were retrospectively reviewed and divided into two groups: those with and those without the computed tomographic finding of subcapsular hepatic necrosis. Extrahepatic fluid, biliary dilatation, circumcaval rings, periportal collar, biochemistry, and random biopsies were correlated with the computed tomographic finding of subcapsular hepatic necrosis. Results: Computed tomographic finding of subcapsular hepatic necrosis was demonstrated at some point in 21 (42%) patients and was never demonstrated in 29 (58%) patients. The association of periportal collar with the computed tomographic finding of subcapsular hepatic necrosis was significant; there was no significant association with other computed tomographic findings. There was no significant difference in serum transaminases between the two groups. There was no significant difference in necrosis on biopsy between the two groups; however, the association of acute cellular rejection with the computed tomographic finding of subcapsular hepatic necrosis was significant. Conclusions: Computed tomographic finding of subcapsular hepatic necrosis is a common finding following liver transplantation, which has little clinical prognostic significance. Received: 13 December 1994/Accepted: 5 January 1995     

Rectus sheath hematoma: diagnostic classification by CT

A method of classification for hematomas of the rectus abdominis sheath (RSH) is proposed based on findings observed in CT in the 13 cases of RSH in the present study. Type I hematomas (five cases) are slight and do not require hospitalization. Type II (three cases) and type III (five cases) are moderate and severe hematomas, respectively, and do require hospitalization. The patients with type III hematomas were all undergoing anticoagulant therapy and presented with a picture of acute abdomen, and in all five cases blood transfusion was carried out. Ultrasonography and, in particular, CT permitted a correct diagnosis of RSH. RSH should be considered (anticoagulant therapy induced) in females with sudden abdominal pain to avoid unnecessary surgical intervention. Received: 1 May 1995/Accepted: 12 June 1995     

Appendiceal stump abscess

Recurrence of traditionally treated appendicitis is rarely reported but known to surgeons and is probably underestimated. We described a case, illustrated by CT, of stump abscess 2 years after laparoscopic appendectomy. Sonography and CT are helpful in detecting pericecal changes, but diagnosis is confirmed by laparotomy. Received: 28 September 1994/Accepted: 22 October 1994     

Enhancing ascites: an aid to CT diagnosis

Enhancement of ascitic fluid on delayed contrast-enhanced CT has been described as a potential pitfall in diagnosis. We present a case in which the phenomenon was beneficial to diagnosis. Enhancement of ascites was useful in delineating the entire extent of a cystic pelvic mass. We also discuss probable molecular and histologic mechanisms responsible for this unique type of enhancement. Received: 8 August 1994/Accepted after revision: 17 November 1994     

Subcapsular renal spread of a pancreatic pseudocyst

In pancreatitis, the fluid collection may extend to unusual sites and organs and form a pseudocyst. We present US and CT findings of a pancreatic tail pseudocyst extending into the subcapsular space of the left kidney. Received: 23 December 1994/Accepted: 25 January 1995     

Mucin-hypersecreting papillary cholangiocarcinoma presenting as abdominal wall abscess: CT and spiral CT cholangiography

We describe CT findings of a case of mucin-hypersecreting papillary cholangiocarcinoma (MHPC), with extrahepatic bile leakage to the rectus abdominis muscle via the ligamentum teres hepatis forming an abdominal wall abscess. Endoscopic retrograde cholangiography was unsatisfactory. Spiral three-dimensional CT cholangiography was helpful in assessing the resectability of MHPC by offering anatomic details of the uninvolved biliary tree. Received: 20 February 1995/Accepted: 4 April 1995     

Duodenojejunal intussusception with biliary obstruction and atrophy of the pancreas

Enteroenteric intussusceptions in adults are rare events caused by tumors in most cases. A case of duodenojejunal intussusception is presented which became manifest because of marked biliary obstruction and extensive pancreatic atrophy. As lead point, a large duodenal polypous hamartoma could be identified. The role of ultrasound and CT as diagnostic imaging of choice in this entity are discussed. Received: 1/16/95Accepted: 2/14/95     

Peritoneopleural communication associated with cirrhotic ascites: scintigraphic demonstration

Demonstration of peritoneopleural communication in patients with cirrhotic ascites has an important impact on treatment planning. We studied 12 such patients and found presence of peritoneopleural communication in five. Two had bilateral, one right-side and two left-side, pleural effusion. Pleural fluid protein content was less than 2 g/dL in all patients. Received: 30 January 1995/Accepted: 4 March 1995