Radiological study of the duodenum in celiac disease in adults

Celiac disease (CD) is the most common form of malabsorption in childhood when it presents with diarrhea and growth failure, a jejunal biopsy is considered the first diagnostic investigation by some authors. In adulthood, clinical symptoms of CD may mimic several different disease, such as peptic ulcer and IBS, and the first diagnostic investigation is an upper GI series. Radiological features of duodenum and small bowel were evaluated in twenty patients with adult onset celiac disease. Sign of duodenitis such as thickened folds, mucosal nodules, dilatation of duodenum and erosions were observed in 19 out of our 20 patients (95%); particularly, thickened folds in 17 (85%), nodularity in 16 (80%), duodenal dilatation in 12 (60%) and erosions in 4 (20%). In celiac disease the lesions are more severe in the upper part of small bowel, and duodenitis may be the unique sign of CD. Duodenitis may be part of a disease involving the entire small bowel; so, a duodenitis observed in the upper gastrointestinal tract requires the study of the entire small bowel--which seems to be very important in the case of celiac disease.     

Radiologic aspects of the surface mucosa of the duodenal bulb. Correlation with the endoscopic and histological aspects

Double contrast barium meal, endoscopy and histology of the duodenal bulb were blindly compared in 47 consecutive patients. The agreement in the judgement of normality of the mucosal surface between radiology and endoscopy was 78%. The agreement in the diagnosis of presence or absence of nodularity and thickened folds was respectively 91% and 87%. The findings of nodularity correspond to duodenitis with pyloric metaplasia or to heterotopic gastric mucosa, while the thickened folds correspond to duodenitis with pyloric metaplasia, Brunner's hyperplasia, lymphatic nodular hyperplasia or cystic glandular dilatation. The diagnostic errors in the radiological examinations in respect to endoscopy is quite important in the case of erosions.     

Multiphasic examinations of the stomach: efficacy of individual techniques and combinations of techniques in detecting 153 lesions

Multiphasic examinations of 153 gastric abnormalities observed radiologically and endoscopically were reviewed to determine the efficacy of four radiologic techniques and of several common combinations of these techniques for examining the stomach. There were 68 gastric ulcers, 12 ulcer scars, 44 cases of gastritis including 27 with erosions, 24 benign neoplasms, and five malignancies. Double-contrast, compression, mucosal relief, and full-column techniques detected 82%, 65%, 62%, and 51%, respectively, of all lesions diagnosed with the complete multiphasic examinations. Results indicate that the greater the number of techniques employed, the more accurate the examination, with biphasic and multiphasic examinations detecting 9%-18% more lesions overall than simple single- or double-contrast studies.     

Enlarged gastric folds in association with Campylobacter pylori gastritis

Enlarged gastric folds in pediatric patients are uncommon. Fifteen patients with upper gastrointestinal (GI) tract symptoms of chronic epigastric abdominal pain, vomiting, or hematemesis underwent radiologic upper GI barium studies and were found to have Campylobacter pylori gastritis at endoscopic biopsy. Seven patients (47%) with C pylori gastric disease had radiologic evidence of enlarged folds. There was no clinical or pathologic evidence of Ménétrier disease. Therefore, C pylori gastritis should be considered in the differential diagnosis of children with upper GI tract symptoms and radiologic evidence of enlarged folds.     

Radiographically diagnosed antral gastritis: findings in patients with and without Helicobacter pylori infection

The purpose of this study was to characterize the radiographic findings of antral gastritis and to determine whether there are differences in the appearance of antral gastritis in patients with and without Helicobacter pylori infection. A search of radiology, endoscopy and pathology files revealed 90 patients with antral gastritis on double contrast upper gastrointestinal tract studies who had endoscopy with testing for H. pylori. The barium studies were evaluated to further characterize the findings of antral gastritis without knowledge of the H. pylori status of the patients or of the endoscopy or pathology findings. The radiographic findings of antral gastritis included thickened folds in 67 patients (74%), polypoid antral gastritis (a subset of patients with thickened folds) in 6 (9%), antral erosions in 21 (23%), enlarged areae gastricae in 14 (16%), crenulation of the lesser curvature in 4 (4%), mucosal nodularity in 2 (2%), a hypertrophied antral-pyloric fold in 2 (2%) and antral striae in 1 (1%). 43 patients (48%) with antral gastritis were H. pylori positive and 47 patients (52%) were H. pylori negative. Thickened folds were detected in 39 H. pylori-positive patients (91%) with antral gastritis vs 28 H. pylori-negative patients (60%) (p<0.001); polypoid gastritis in 6 H. pylori-positive patients (14%) vs 0 H. pylori-negative patients (p<0.05); enlarged areae gastricae in 14 H. pylori-positive patients (33%) vs 0 H. pylori-negative patients (p<0.0001); and antral erosions in 2 H. pylori-positive patients (5%) vs 19 H. pylori-negative patients (40%) (p<0.0001). Our experience suggests that antral gastritis caused by H. pylori infection is associated with characteristic features on double contrast studies (including thickened folds, polypoid gastritis and enlarged areae gastricae) and that this condition is rarely associated with antral erosions. Thus, radiologists can often suggest whether the patient's gastritis is caused by H. pylori on the basis of radiographic findings.     

Sacroiliitis: MR imaging findings

Magnetic resonance (MR) imaging was performed in seven asymptomatic volunteers and 17 patients with clinical and radiologic evidence of sacroiliitis. MR imaging findings were compared with those at computed tomography (CT) to determine the MR imaging appearance of the sacroiliac joint when normal and in sacroiliitis. The normal articulation was well depicted with MR imaging. Findings of sacroiliitis were identified in 20 sacroiliac joints (12 patients). MR imaging findings characteristic of sacroiliitis included abnormal cartilage signal intensity (95% of joints) and erosions (75% of joints) on T1-weighted images. Areas of increased intensity in the articulation (80% of joints) or in erosions (60% of joints) were seen on T2-weighted images. MR imaging was superior to CT for evaluation of cartilage and detection of erosions. Four sacroiliac joints (20%) and two patients (17%) with MR imaging findings of sacroiliitis were negative at CT. The authors conclude that MR imaging is a valuable method for detecting sacroiliitis, particularly when results of other imaging techniques are inconclusive.     

Barrett esophagus as an extension of severe esophagitis: analysis of radiologic signs in 29 cases

Twenty-nine cases of Barrett esophagus verified by endoscopy and 16 cases confirmed by histology were reviewed for pertinent radiologic signs. All patients had barium-filled and mucosal relief films, and all but five cases had double-contrast films. Common radiologic signs in descending order were thickened and irregular mucosal folds (28/29), hiatal hernia (26/29), esophageal stricture (25/29), esophageal ulcer (20/29), distal esophageal widening (19/29), granular mucosal pattern (16/24), reticular mucosal pattern (9/24), and intramural pseudodiverticula (6/29), all of which are also recognized signs of reflux esophagitis. Midesophageal stricture, esophageal ulcer, and distal esophageal widening were particularly indicative of Barrett esophagus. Since there appears to be no specific sign of Barrett esophagus, a multifaceted approach is suggested concentrating on the association of Barrett esophagus with the radiographic signs of severe reflux esophagitis.     

Detection of gastric erosions: comparison of biphasic radiography with fiberoptic endoscopy

Biphasic radiography was compared with fiberoptic endoscopy in detecting gastric erosions in a prospective, blinded study of 385 patients with dyspepsia. Because no absolute standard was available for the comparison, since histologic confirmation of all erosions was not possible, the kappa statistic was used to compare results from both modalities. Flat (incomplete) erosions were detected with endoscopy only and were considered to be present in 42 patients (11.2%). Varioliform (complete) erosions were identified with both radiography and endoscopy in 12 patients (3.2%). For the detection of varioliform erosions, a substantial agreement beyond chance between both modalities was found (kappa = 0.73; standard error, 0.12). Thus, flat erosions were detected with endoscopy only, whereas state-of-the-art radiography and endoscopy were equally sensitive for detecting varioliform erosions. Histologic confirmation of erosions was obtained in only 75% of the patients. It is unknown whether the demonstration of erosions with radiography and/or endoscopy correlates with dyspepsia.     

Radiologic appearance of complete gastric erosions.

At gastroscopy of 656 patients, complete gastric erosions were found in 58 (11%). Radiography performed in 46 of these demonstrated erosions in 21 of 33 with a time span less than one month between radiography and gastroscopy but in only 4 of 13 with a time span of one to 3 months. Double contrast technique supplemented with films of compressed barium-filled antrum demonstrate the lesions best. Complete erosions have often appearances simulating gastric polyps or large mucosal folds and are often found together with ulcers.     

Rheumatoid arthritis: MR imaging manifestations

Radiologic assessment of the stage and treatment response of rheumatoid arthritis (RA) is based on the presence of bone erosions, joint-space narrowing, and osteoporosis. Most radiologic methods for staging RA lack interobserver correlation and are time consuming. Magnetic resonance (MR) imaging provides excellent depiction of soft-tissue abnormalities of the joints affected by RA, which allows detection of early changes. Nineteen joints of 17 patients with RA were studied with surface-coil MR imaging. Measurable abnormalities demonstrated by MR imaging but not clearly seen on plain radiographs included bone erosions, joint effusion, synovial sheath effusion, and cartilage irregularity and thinning. Seven patients of this group underwent MR imaging before and after 6 months of gold therapy. Four patients had significant interval changes on MR images that were not seen on plain radiographs. MR imaging may become a sensitive and objective method for quantitative assessment of the joint changes of RA.     

Radiological assessment of dysphagia with endoscopic correlation

Four hundred fifty consecutive patients with dysphagia were evaluated radiologically over a 14-month period; 127 of these (28.2%) were also examined endoscopically. The most common abnormality seen was dysmotility (34%), followed by hiatal hernia, benign stricture, and esophagitis. Correlation with endoscopy was generally good. Radiologic study demonstrated all cases of esophageal malignancy; radiologic/endoscopic correlation was also strong in patients with moderate or severe esophagitis, though the radiologist had some difficulty detecting mild inflammation. Endoscopy failed to demonstrate some benign strictures. Radiologic study was relatively accurate in detecting significant organic disease; most motility disorders were not detected by endoscopy. For these reasons, as well as lower cost, increased convenience, and patient comfort, radiologic assessment is recommended as the primary method of evaluating patients with dysphagia.     

Determination of the best diagnostic criteria of sacroiliitis with MRI

AIM: To determine which signs are the most accurate in the diagnosis of sacroiliitis with MRI. MATERIAL AND METHODS: 40 consecutive patients with inflammatory low back pain underwent MRI at 1.5 T with FSE T2 and SE T1 weighted-images before and after Gadolinium-DOTA injection. 22 patients were suffering from spondylarthropathy while the other 18 patients constituted the control group. Each examination was interpreted by two independent observers who analysed 11 different signs. RESULTS: Intra and inter observer reproducibility were high (respectively 76% and 70%). Inter observer reproducibility was excellent for bone marrow edema (89%) but low for bone productions (38%). Three lesions displayed a high positive predictive value: ligamentous contrast enhancement (86%), bone marrow edema (80%) and bone erosions (70%). Intra articular enhancement of the sacro-iliac joint was a less sensitive sign than bone marrow edema. CONCLUSION: This study confirms the excellent positive predictive value of MRI for an early diagnosis of active sacroiliitis. Bone marrow edema seems to be a more pertinent sign than intra articular enhancement.     

The radiologic detection of duodenal ulcers: effects of examiner variability, ulcer size and location, and technique

Study of 91 endoscopically verified duodenal ulcers compared the effects of examiner variability, ulcer size and location, and radiographic technique on ulcer detection. Radiologic sensitivity of 61.5% was found for the entire group of 91 ulcers. Examiner variability was the strongest determinant of success; sensitivities for individual examiners ranged from 44.4% to 80%. Ulcer size was a second factor in radiologic detectability; ulcers 5 mm or larger were detected at a higher rate (80.0%) than those less than 5 mm (64.5%). Sensitivities of 65.9% and 57.4% were recorded for single- and double-contrast examinations, respectively, a statistically insignificant difference.     

Fibrous dysplasia vs adamantinoma of the tibia: differentiation based on discriminant analysis of clinical and plain film findings

Differentiation between benign fibrous dysplasia and malignant adamantinoma of the tibia is challenging because of the impact the diagnosis has on the choice of treatment (none or extensive surgery). The histologic and pathologic similarities of the lesions and the controversial relationship between fibrous dysplasia, osteofibrous dysplasia, and adamantinoma complicate the matter. We found a large overlap of histologic features in lesions considered either fibrous dysplasia or osteofibrous dysplasia on the basis of the radiologic findings. The purpose of this study was to determine the value of the plain radiograph of the lower leg in combination with clinical findings to differentiate the benign from the malignant condition. The clinical symptoms, radiographs, and histologic slides of 46 patients with fibrous dysplasia and 22 with adamantinoma in the tibia were reviewed retrospectively. In only one of 12 patients with radiologic or histologic characteristics of osteofibrous dysplasia were both radiologic and histologic criteria for the diagnosis present. A linear discriminant analysis was performed on six clinical (age, spontaneous pain, pain after trauma, swelling only, pain and swelling, and bowing deformity) and 25 radiologic signs. Fibrous dysplasia and its variant osteofibrous dysplasia could be identified correctly in 87% (40 of 46 patients) and adamantinoma in 95% (21 of 22 patients) by using the patient's age and four radiologic signs. When results from the discriminant analysis of a randomized subgroup of patients (32) were used on the other subgroup (36 patients), fibrous dysplasia was correctly identified in 84% (21 of 25) and adamantinoma in 82% (nine of 11). Fibrous dysplasia is more prevalent than adamantinoma in a young patient, when radiographs show a ground-glass appearance and anterior bowing and when there is no multilayered periosteal reaction and moth-eaten destruction. When radiologic signs and the patient's age are combined, fibrous dysplasia and adamantinoma can be discriminated in a high percentage of patients.     

Jejunal fold separation in adult celiac disease: relevance of enteroclysis

The number of folds in the proximal jejunum was measured retrospectively in 25 studies of patients with adult celiac disease and 75 control subjects. The average number of folds per inch of proximal jejunum in the group with celiac disease was 2.88 (none to five), as against 4.88 (three to seven) in the controls. The difference was less pronounced in the distal ileum. A "mosaic pattern" was demonstrated in three patients. Positive radiologic evidence of celiac disease could be elicited in 76% of the patients' studies. Demonstration of five or more folds in the jejunum and/or three or fewer folds in the ileum would have been evidence against a diagnosis of celiac disease in 67 of the 75 controls. Indications for the use of radiography in celiac disease are reassessed.     

Self-expanding metal stents for palliative treatment of malignant ureteral obstruction.

OBJECTIVE. We studied the immediate and long-term efficacy of the Wallstent device in the treatment of ureteral obstruction caused by malignant disease. SUBJECTS AND METHODS. In 23 patients (30 ureters), self-expanding metal stents were implanted endoscopically (n = 23), percutaneously (n = 5), or bidirectionally (n = 2) because of extrinsic malignant ureteral obstruction. Patients who met the following criteria were selected for stent implantation: (1) life expectancy of at least 6 months, (2) current polychemotherapy, (3) increasing levels of serum creatinine, and (4) severe clinical signs and symptoms associated with hydronephrosis. Obstruction was diagnosed by using sonography and excretory urography. After radiologic localization and dilatation of the stenosis, the Wallstent device was inserted. For 4 weeks, a double-J catheter inserted through the stent was kept in place in order to prevent obstruction by reversible hyperplastic reaction of the urothelium. Patients were followed up for 31 weeks (range, 3-75 weeks). Follow-up included sonography, excretory urography, and determination of serum levels of creatinine in all cases and furosemide scintigraphy and the Whitaker test in selected cases. RESULTS: Implantation of the Wallstent device was successful in 30 (97%) of 31 cases attempted. The survival rate was 81% after 6 months and 61% after 8 months. The primary patency was 83% after 30 weeks. Complications were macrohematuria (one patient) and incrustation (two patients). No infection and no migration or compression of the stent were observed. CONCLUSION. Implantation of a Wallstent device is a safe and effective alternative to double-J catheter placement in tumor-associated ureteral obstruction.     

Radial meniscal tears: significance, incidence, and MR appearance

OBJECTIVE: The purpose of this study was to assess the prevalence of radial meniscal tears at arthroscopy and the ability of MRI to detect radial tears preoperatively. In addition, the ability of four radiologic signs to detect radial tears was assessed. Those signs are the truncated triangle, cleft, marching cleft, and ghost meniscus signs. MATERIALS AND METHODS: Arthroscopy of the knee was performed by a single orthopedic surgeon on 196 consecutive patients. The surgeon noted each radial tear he encountered. The MR images that were obtained at our institution were reviewed, whereas those patients who were imaged elsewhere were excluded. The preoperative MRI reports were reviewed to assess the ability to prospectively identify radial meniscal tears. In addition, a retrospective analysis of the MRI studies was performed by two radiologists in which four radiologic signs were applied to detect radial tears. RESULTS: Twenty-nine patients (15%) had radial tears at arthroscopy. Eighteen of the 29 patients had their imaging performed at our institution and were selected for review. There were 19 radial tears found at surgery. Seven (37%) of the 19 tears were identified as radial prospectively. Retrospectively, using the four signs for radial tears, reviewers identified 17 (89%) of 19 radial tears. CONCLUSION: A more accurate preoperative diagnosis may be rendered using the four described signs to detect radial tears, thus allowing informative preoperative counseling and consideration of new therapies that are available for radial meniscal repair.     

Double contrast barium enema in Crohn's disease and ulcerative colitis.

Double contrast barium enema examinations in 24 patients with Crohn's disease of the colon and 29 patients with ulcerative colitis were reviewed without knowledge of the clinical diagnosis. The radiologic diagnosis of Crohn's disease agreed with the clinical diagnosis in 98% of patients. In this condition the most common radiologic findings were discontinuous or asymmetric disease (88%) and discrete ulcers (67%) often on a normal mucosa. The latter are characteristic of early Crohn's disease and may enable the radiologist to be the first to suggest the diagnosis, particularly when both sigmoidoscopy and small bowel examination are normal. Of the patients with ulcerative colitis, a positive radiologic diagnosis was made in 83% on the basis of a granular mucosal pattern (79%) and continuous distal involvement (86%). The high accuracy of the double contrast technique, especially in Crohn's disease, and the relative specificity of the signs that it can demonstrate suggest that this is the preferred examination in the radiologic evaluation of inflammatory bowel disease.     

Clinical significance of erosive azotemic osteodystrophy: a prospective masked study

Objective. To determine the relationship between joint symptoms and radiographically identifiable erosions in patients on maintenance hemodialysis for 4 or more years. Patients and design. A prospective study was carried out on 21 patients who underwent rheumatological evaluation and radiographic surveys of all clinically examined joints. The radiologist was masked to the clinical information and the clinicians were masked to the radiographic findings. Cuprophane dialyzers were used on all patients. The statistical analysis was performed by unpaired t-test and Fisher’s exact test. Results and conclusions. Ten men and 11 women comprised the 21 patients, of whom 10 had joint symptoms and clinical signs whereas 11 did not. Age, gender, and duration of hemodialysis did not differ significantly between the symptomatic and asymptomatic group. Of the 21 patients, 10 had radiological evidence of erosions and 11 did not. The average age of patients with erosions was 64.9 years; this was significantly different from the age of the group without erosions, which was 54.1 years. The group with radiographic evidence of erosions had been on dialysis for an average of 9.6 years, while those without erosions had received dialysis for an average of 6.4 years. Of the 11 patients without radiographic evidence of erosions, three were symptomatic. Of the 10 patients with erosions, seven had musculoskeletal symptoms, but only in four was there concordance between radiological findings and symptoms of the corresponding joints. The positive predictive value of radiographic erosions in predicting clinically significant disease was 40%. There was poor correlation between the presence of radiographic erosions and clinical signs and symptoms of joint disease. Received: 15 June 1998; Revision requested: 1 October 1998; Revision received: 20 October 1998; Accepted: 23 October 1998     

Predictive value of small bowel radiography for recurrent Crohn Disease

Small bowel radiographs of 53 patients who had remote surgery for Crohn disease were reviewed. In 10 of these, the radiographic studies could be compared with pathologic specimens from recent reoperations. The correlation of radiographic features and photographic and histopathologic alterations in these specimens was very close. Normal radiographs were found in 21 patients. In the other 32 patients, various types of inflammatory lesions were recorded. Submucosal edema was seen as broad folds in 23 patients, as irregular folds in 10 patients, and as absence of mucosal folds in nine patients. Superficial ulcerations were seen in 22 patients. Transmural lesions were seen in 14 patients but were seldom pronounced. Patients with normal postoperative small bowel radiographs had no signs of clinical recurrence, whereas 27% (4/15) of those with submucosal edema and superficial ulcerations had clinical signs of recurrence. In 87% (13/15) of patients with transmural lesions, there was clinical recurrence. Local progression could be documented in two of 20 patients. There were no instances of axial progression. Postoperative small bowel radiography seems to have useful predictive value for recurrent Crohn disease.