Hyaline vascular-type Castleman disease: a rare cause of a hypervascular retroperitoneal mass

We present the cross-sectional imaging and angiographic findings of hyaline vascular-type Castleman disease located in the retroperitoneum. The diagnosis was made postoperatively. This entity can simulate a malignant neoplasm. The histologic subtypes and presentations of Castleman disease and the differential diagnosis of retroperitoneal masses are discussed. Received: 12 August 1999/Accepted: 8 September 1999     

Abdominal involvement in neurofibromatosis 1: sonographic findings

Background: Neurofibromatosis 1 (NF1) has been studied from many viewpoints, but its abdominal involvement has rarely been reported. Sonography (US) is now the initial diagnostic tool for abdominal exploration, which prompted us to determine the clinical manifestations and US findings of abdominal involvement in NF1. Methods: We analyzed the US findings and clinical data of eight NF1 cases with abdominal involvement. Results: Abdominal involvement included neurofibromatous tumor growth in the liver, mesentery, and retroperitoneum, in addition to mesenteric leiomyomatosis and gastric carcinoma. Color Doppler US was useful not only in detecting blood flows in the lesions but also in preventing hazardous vascular injury during tumor biopsy. Conclusion: A better understanding of the clinical manifestations and US findings of abdominal involvement in NF1 translates into improved NF1 patient care. Received: 6 October 1999/Revision accepted: 26 January 2000     

Retroperitoneal edema: sonographic mimic of retroperitoneal fluid collection

Background: The sonographic finding of an anechoic retroperitoneal abnormality suggests a fluid collection (e.g., abscess, urinoma, hematoma). Our study was performed to evaluate cases in which this sonographic finding appeared to be a manifestation of systemic edema. Subjects and Methods: Inpatient sonograms performed over a 40-month period were reviewed for the presence of anechoic areas suggestive of fluid collection in the retroperitoneum of the flank. Records of patients with such findings were reviewed for evidence of retroperitoneal abscess, urinoma, or hemorrhage, as well as for the presence and cause(s) of peripheral edema. Results: Of the 29 patients identified with sonographic findings suspicious for retroperitoneal fluid collection, 13 (45%) had no cause for and no clinical evidence of focal retroperitoneal collection. All 13 patients had peripheral edema attributable to hypoalbuminemia, congestive heart failure, overhydration, cirrhosis, and/or the systemic inflammatory response (multiple organ failure) syndrome. Resolution of the retroperitoneal abnormality following therapy for congestive heart failure was documented in one case, and CT scan confirmed retroperitoneal edema in another. Conclusion: Anechoic regions that represent edema can be seen on sonograms of the retroperitoneum in patients with conditions that cause edema in other regions. The possibility of edema mimicking a fluid collection should be particularly considered prior to invasive procedures in the retroperitoneum. Received: 7/12/96/Accepted: 9/4/96     

Retroperitoneal foregut cyst

A foregut cyst is formed as a result of abnormal budding and pinching of the tracheobronchial tree when bronchial buds develop to form the primitive respiratory tree. Foregut cysts are clinically classified as bronchogenic, esophageal, enterogastric, or ciliated hepatic. We present a foregut cyst that occurred in the retroperitoneum and was difficult to distinguish from other retroperitoneal cystic mass lesions. Magnetic resonance imaging was useful in revealing the cyst's continuity to adjacent organs. Received: 19 June 1995/Accepted: 23 July 1995     

Sonographic diagnosis of intussusceptions in adults

Differentiating bowel intussusception occurring in adults from other bowel diseases represents a diagnostic problem because this condition is not a common finding. Contrast radiography, computed tomography, magnetic resonance imaging, and abdominal ultrasonography are imaging techniques suitable for this diagnosis. Sonography is easy to perform, reproducible, and less invasive than the other techniques. The aim of the present study was to evaluate the diagnostic utility of abdominal sonography in four patients affected by bowel intussusception and to assess the advantages offered by this method. Received: 9 March 1999/Accepted: 7 April 1999     

Mesenteric cyst: sonographic findings

Background: Mesenteric cyst (MC) is a relatively rare disease, and its sonographic characteristics have not been sufficiently analyzed. Methods: We studied the sonographic findings of eight patients with MC, with attention paid to its size, shape, internal echoes, and especially the presence or absence of lateral shadowing and the mode of back echoes. In four cases, the sound velocity and acoustic impedance of cystic fluid were also measured. The mode of blood flow was evaluated by color Doppler sonography. Results: Six cases showed an oval or comma-shaped mass. Internal echoes were present in six cases, and two of them showed a pseudosolid pattern. In these cases, M-mode sonography confirmed the movement of these internal echoes. Only one case showed a posterior echo enhancement, and no case showed lateral shadowing. Sound velocity measured in four cases was 1515–1537 m/s, with an acoustic impedance of 1.550–1.576 kg/m²/s. No blood flow signals were obtained from the lesion. Conclusion: MC exhibits so many patterns on ultrasound that we should consider the possibility of MC when encountering an avascular oval mesenteric mass. Received: 30 August 1999/Accepted: 6 October 1999     

Intrahepatic splenosis: imaging features

We report a patient who presented with asymptomatic focal liver lesions and in whom a diagnosis of intrahepatic splenosis was made. This rare condition mostly occurs in patients who previously underwent splenic trauma or surgery. Magnetic resonance imaging (MRI) characteristics suggesting this diagnosis are described. The lesions were mainly hypointense on T1- and hyperintense on T2-weighted images. After administration of small iron oxide particles (SPIO-Endorem), the lesions remained slightly hyperintense relative to the hypointense liver parenchyma but showed a 50% loss in signal intensity. Knowledge of these MRI characteristics may avoid the use of surgical interventions to arrive at the correct diagnosis of these rare liver lesions. Received: 14 June 1999/Accepted: 14 July 1999     

Gaucher disease of the spleen: CT and MR findings

We present a 26-year-old male patient with Gaucher disease who presented with epigastric pain and a palpable mass in the left abdomen. Ultrasound, abdominal computed tomography, and magnetic resonance imaging showed massive splenomegaly with multiple splenic nodules up to 7 cm in diameter. Splenic nodules should be included in the differential diagnosis of splenic masses. Follow-up is necessary because of the increased incidence of hematologic malignancies in Gaucher disease. Received: 28 September 1999/Accepted: 20 October 1999     

Spiral CT virtual endoscopy of abdominal arteries: clinical applications

Virtual endoscopy enables the creation of endoluminal views of the aorta and its branches by processing spiral computed tomographic (CT) images, thereby allowing the preoperative and postoperative evaluations of abdominal aortic aneurysms, aneurysms of the splenic, celiac, and common iliac arteries, and renal artery stenoses. Moreover, it is helpful for verifying the position of stents and endoprostheses from within the aortic lumen. This method is a promising addition to spiral CT. Received: 3 May 1999/Accepted: 2 June 1999     

Arteriovenous fistula secondary to iliac mycotic aneurysm: helical CT findings

We describe the case of a 59-year-old man who presented a mycotic aneurysm of the common right iliac artery due to Streptococcus agalactiae and developed an arteriovenous fistula within the inferior vena cava secondary to spontaneous rupture of the aneurysm. The clinical syndrome, helical computed tomographic, and angiographic findings are described and discussed. Received: 25 February 1999/Accepted: 7 April 1999     

Torsion of the fundus of gallbladder demonstrated on ultrasound and treated with ERCP

A rare case of torsion of the gallbladder fundus, which was diagnosed by ultrasound and endoscopic retrograde cholangiopancreatography (ERCP) and released during ERCP, is presented. The case illustrates the sonographic and ERCP findings of this rare condition and suggests using ERCP as a therapeutic tool. Received: 9 July 1999/Revision accepted: 3 November 1999     

Altered flow dynamics of intravascular contrast material to the liver in superior vena cava syndrome: CT findings

Background: To evaluate the findings of altered flow dynamics in the livers of patients with obstruction of superior vena cava (SVC) on helical computed tomography (CT). Methods: In six patients (age range = 28–80 years) with SVC obstruction, CT findings were retrospectively reviewed to identify the abnormal enhancement patterns of the liver and the relation with the extrahepatic collateral vessels and hepatic vessels. Results: Abnormal hepatic enhancement was observed in the following four (A–D) portions: (A) anterior portion of segment IV (n = 5), (B) subdiaphragmatic portion of the liver (n = 4), (C) posterior portion of the right lobe (bare area; n = 1), and (D) lateral segment of the left lobe (n = 2). Two major collateral pathways to the liver were demonstrated as follows: A and D → from the umbilical vein to the left portal vein, and B and C → from the subcapsular vein to the bare area of the liver or to the hepatic veins. On helical CT, these collateral pathways were also clearly visualized. Conclusion: When these abnormal enhancements of the liver on CT are recognized within the liver, these findings indicate diversion of contrast material into collateral pathways to the liver with SVC obstruction. Received: 31 March 1999/Revision accepted: 25 June 1999     

Spontaneous thrombosis of a pseudoaneurysm complicating pancreatitis

Patients with a visceral aneurysm are at high risk for acute transpapillary, intra-, or retroperitoneal hemorrhage, necessitating either surgical or endovascular therapy. We report an instance of spontaneous thrombosis of a pseudoaneurysm complicating pancreatitis before endovascular treatment could be performed. Causality and the literature of spontaneous thrombosis in pseudoaneurysms are discussed. Received: 14 December 1998/Accepted: 13 January 1999     

Percutaneous balloon dilatation for benign hepaticojejunostomy strictures

Background: Percutaneous balloon dilatation of biliary tract strictures is generally accepted as a safe and inexpensive procedure. The effectiveness in selected groups of patients remains under discussion. The purpose of this study was to evaluate the results of percutaneous balloon dilatation in patients with a benign stricture of a hepaticojejunostomy. Methods: Fifteen patients with a benign stricture of a hepaticojejunostomy were examined between 1993 and July 1997. An ultrasound-guided percutaneous transhepatic cholangiography (PTC) procedure was performed, followed by a balloon dilatation. Follow-up was performed prospectively by outpatient visits and laboratory testing. Results: Percutaneous dilatation was successful in 14 patients. Three patients developed a recurrence. In one of these patients, the procedure was repeated successfully. Gastrointestinal bleeding occurred in one patient. The success rate for balloon dilatation in this group of patients was 73% after a mean follow-up of 30 months. When the procedure was repeated, the success rate was 80% after a mean follow-up of 33 months. Conclusions: Percutaneous balloon dilatation for benign hepaticojejunostomy strictures is feasible in the majority of patients and produces acceptable medium-term to long-term results. Advantages are its minimal invasive character and the fact that all options remain open in case of failure. Received: 25 June 1999/Accepted: 28 July 1999     

Complications of “dropped” gallstones after laparoscopic cholecystectomy: technical considerations and imaging findings

New laparoscopic techniques have revolutionized the practice of surgery. Laparoscopic cholecystectomy has become one of the most commonly performed surgeries worldwide. Although shorter hospital stays and patient comfort have offered clear advantages over open cholecystectomy, the technique has resulted in several specific complications, including bile duct injury and gallbladder perforation. Although rarely clinically significant, intraperitoneal gallstone spillage can cause abscess formation and adhesions. Although these patients can present with a confusing clinical picture, their characteristic radiologic features should be recognized. We present two cases of complicated intraperitoneal gallstone spillage radiologically diagnosed and treated with laparoscopic and interventional radiologic techniques. Received: 13 April 1999/Accepted: 19 May 1999     

Evaluation of the intratumoral vasculature of hepatocellular carcinoma by power Doppler sonography: advantages and disadvantages versus conventional color Doppler sonography

Background: To determine whether a difference exists in the relative ability of power Doppler sonography and conventional color Doppler sonography to detect the intratumoral vasculature of hepatocellular carcinoma based on lesion size and location. Methods: Sixty patients with 88 hepatocellular carcinoma lesions that showed tumor staining on angiography and were enhanced on dynamic computed tomography were evaluated. Power Doppler sonography and color Doppler sonography were used to detect the intratumoral vasculature, and their sensitivity to blood flow was evaluated. Results: Power Doppler sonography showed a superior detection rate for lesions smaller than 2 cm and located 4–8 cm from the abdominal surface in the right hepatic lobe as compared with color Doppler sonography (p < 0.01). Neither power Doppler sonography nor color Doppler sonography depicted the intratumoral vasculature of lesions located more than 8 cm from the abdominal surface (n = 14). Both color Doppler imagings exhibited a low detection rate for lesions in the left hepatic lobe (n = 31, p < 0.01). Conclusions: Power Doppler sonography should be applied in the evaluation of small or intermediate depth lesions because it is more sensitive to these lesions than color Doppler sonography, but it is not useful for left lobe and deep lesions. Received: 31 March 1999/Accepted: 14 July 1999     

Resection of liver granulomas under a diagnosis of metastases from breast cancer

Three cases of liver granuloma mistakenly diagnosed as metastases from breast cancer are described. No common cause for granuloma formation in the liver was evident among the patients. Although surgical intervention to obtain a definitive diagnosis may occasionally be necessary, care needs to be exercised in the preoperative diagnosis of liver tumors. The growth rate of the lesions may be an important factor to consider. Received: 3 August 1999/Accepted: 8 September 1999     

Four-year study of abdominal ultrasound in 900 Central African adults with AIDS referred for diagnostic imaging

Background: In the majority of sub-Saharan African countries, the absence of computed tomography facilities makes abdominal ultrasound (US) an alternative diagnostic tool in the clinical investigation of infectious and noninfectious complications of human immunodeficiency virus (HIV)–infected individuals. We studied the abdominal US findings in Central African adult AIDS patients to determine whether the findings were consistent between different population groups and neighboring countries. We performed a longitudinal study of AIDS patients and age- and sex-matched HIV-negative adults referred for abdominal US at two tertiary referral city hospitals: the Gecamines Sendwe Hospital (GSH), Lubumbashi, Congo, and the University Teaching Hospital (UTH), Lusaka, Zambia. Methods: Between 1992 and 1996, abdominal US findings in 900 adults (300 Congolese adults from GSH and 600 Zambian adults from UTH; age range = 15–55 years) with a diagnosis of AIDS referred for diagnostic imaging from the inpatient medical wards were recorded; 900 abdominal ultrasound findings from age and sex-matched HIV-negative adults were studied for comparative purposes. Results: Abdominal US for diagnostic purposes in AIDS patients is requested by clinicians for a range of primary clinical indications: abdominal pain, fever of unknown origin, hepatosplenomegaly, lymphadenopathy, and abnormal liver function tests. Compared with the HIV− individuals, the AIDS group of patients had a significantly higher proportion of splenomegaly (35% vs. 24%; p≤ 0.001), hepatomegaly (35% vs. 22%; p= 0.001), lymphadenopathy (31% vs. 11%; p≤ 0.001), biliary tract abnormalities (25% vs. 12%; p≤ 0.001), gut wall thickening (15% vs. 5%; p≤ 0.001), and ascites (22% vs. 9%; p≤ 0.001). There were no differences in renal tract and pancreatic abnormalities between the AIDS and HIV− groups. There were significantly fewer gallstones in the AIDS group (23% vs. 75%; p≤ 0.001). These patterns of abdominal US abnormalities were consistent across both hospitals. Conclusions: Diagnostic imaging by abdominal US is commonly used in the management of a variety of clinical indications in Central Africa. The changes seen on abdominal US in AIDS patients appear uniform across the two countries in Central Africa. These findings may have implications for the radiologist, especially in developing countries, where accurate microbiological or pathologic diagnosis of infectious and noninfectious diseases afflicting the HIV-infected patient is often not possible and US is sometimes relied upon as a “diagnostic” investigation by many physicians. Further studies are required to define patterns of clinical findings, plain films, and pathologic and laboratory correlates with US to develop and refine diagnostic algorithms for clinical use in resource-poor countries. Received: 24 June 1999/Revision accepted: 8 September 1999     

Portal tumor thrombus due to gastrointestinal cancer

Methods: We studied the clinical data of seven patients with portal tumor thrombus (PTT) due to gastrointestinal (GI) cancer to determine the radiologic patterns and clinical implications of this rare complication. Results: (a) PTT was located along the entire splenic vein in three cases, at the splenomesenteric confluence in one case, and in the superior mesenteric vein in one case. Intrahepatic PTT occurred in two of four cases with liver metastasis. (b) One cirrhotic case was complicated by the occurrence of colon cancer associated with PTT in the splenic vein; the esophageal varices became rapidly enlarged and poorly controlled, and the patient died due to repeated variceal rupture. (c) In all patients, abdominal sonography (US) detected PTT and color Doppler sonography confirmed the US findings. Conclusions: The splenic vein should be meticulously observed by color Doppler sonography to check for PTT in patients with GI cancer to improve patient care. Received: 29 December 1998/Accepted: 24 February 1999     

Spontaneously reduced midgut malrotation: CT diagnosis

Midgut malrotation is a relatively rare congenital malformation that arises from an error of rotation and fixation of the midgut. We report a case of spontaneously reduced duodenal malrotation diagnosed by computed tomography and roentgenography after the ingestion of barium. Received: 4 December 1998/Revision accepted: 14 July 1999