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     

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     

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     

Bladder pheochromocytoma with ring calcification

A case of a 19-year-old male with a paraganglioma (pheochromocytoma) arising in the prostate and involving the urinary bladder is presented. The radiological studies, including computed tomography, demonstrated ringlike calcification of the tumor, a rare finding that is highly suggestive of the diagnosis of pheochromocytoma. The tumor was excised and found to be malignant at surgery. Received: 17 April 1995/Accepted: 23 May 1995     

Renal cell carcinoma and tumor thrombus neovascularity:MR demonstration with pathologic correlation

A case of renal granular cell carcinoma with inferior vena cava and right atrium involvement is presented. Spin-echo and single breath-hold gradient-recalled-echo magnetic resonance pulse sequences demonstrate a patchy flow signal within the cavoatrial thrombus. This pattern, in correlation with the histopathologic findings, represents tumoral neovascularity characteristic of renal carcinoma venous invasion, which was previously reported by angiography, computed tomography, and color Doppler duplex ultrasound. Received: 27 April 1995/Accepted: 24 May 1995     

Testicular feminization: radiologic considerations in a unique formof cryptorchidism

A case report of complete testicular feminization is presented. The medical and radiological characteristics of this condition which distinguish it from male cryptorchidism and other disorders of sexual differentiation are discussed. To our knowledge, only three previous case reports have been published in the radiology literature. Our report is the first to describe MRI findings. Received: 2 March 1995/Accepted after revision: 28 March 1995     

Jaundice due to afferent loop obstruction following hepatectomy for a hilar cholangiocarcinoma

A case of jaundice due to obstruction of Roux en Y-limb following hepatectomy for a hilar cholangiocarcinoma is presented. Percutaneous transhepatic biliary drainage improved the jaundice but promoted disseminated intravascular coagulopathy. Our limited experience suggested that afferent loops should be drained directly to prevent reflux of enteric contents into the biliary system. Received: 21 February 1995/Accepted: 24 March 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     

Solitary malignant mesothelioma of the small intestine:radiological appearances

Malignant peritoneal mesothelioma is virtually unknown to feature as a solitary lesion. A patient presented with abdominal pain, weight loss, and melena and underwent enteroclysis, computed tomography, and superior mesenteric arteriography. Sharp angulation, narrowing, and mucosal destruction in a jejunal segment, caused by an encapsulating infiltrative mesenteric mass, were shown. The diagnosis of a malignant peritoneal mesothelioma, localized to the small intestine, was made at histology. Received: 13 February 1995/Accepted: 18 March 1995     

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     

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     

Retroperitoneal amyloidosis,factor IX and X deficiency,and gastrointestinal bleeding

A patient with gastrointestinal bleeding due to amyloidosis-related factor X deficiency had extensive calcified retroperitoneal amyloid deposition that was visible on plain radiographs and then localized by computed tomography. The radiologic findings were important in arriving at the proper diagnosis despite negative biopsies. Received: 14 December 1994/Accepted: 15 January 1995     

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     

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     

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     

CT of Hodgkin's lymphoma limited to the gallbladder

A complex mass confined to the gallbladder found on CT is unusual, but nor rare, with causes including benign inflammatory disease, early primary carcinoma and metastases. Non-Hodgkin's lymphoma is rare and Hodgkin's disease, prior to the current case, unheard of involving just the gallbladder. Thus, this should be considered part of the differential diagnosis of a complex gallbladder mass. Received: 9 February 1995/Accepted: 4 March 1995     

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     

Wedge-shaped intrahepatic cholangiocarcinoma:MRI<+>–<+>pathologic correlation

On magnetic resonance imaging (MRI) studies, wedge-shaped areas of signal abnormality noted in association with liver lesions have been attributed to secondary phenomena and are said to be substantially larger than the actual tumor. We describe the MRI and pathological appearance of a wedge-shaped cholangiocarcinoma. In cases where therapy might be affected, biopsy of wedge-shaped MRI abnormalities associated with hepatic malignancy should be considered for accurate tumor staging. Received: 23 December 1994/Accepted: 25 January 1995     

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     

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