Hepatic Sinusoidal Obstruction Syndrome Caused by Herbal Medicine: CT and MRI Features

Objective

To describe the CT and MRI features of hepatic sinusoidal obstruction syndrome (HSOS) caused by herbal medicine Gynura segetum.

Materials and Methods

The CT and MRI features of 16 consecutive Gynura segetum induced HSOS cases (12 men, 4 women) were analyzed. Eight patients had CT; three patients had MRI, and the remaining five patients had both CT and MRI examinations. Based on their clinical presentations and outcomes, the patients were classified into three categories: mild, moderate, and severe. The severity of the disease was also evaluated radiologically based on the abnormal hepatic patchy enhancement in post-contrast CT or MRI images.

Results

Ascites, patchy liver enhancement, and main right hepatic vein narrowing or occlusion were present in all 16 cases. Hepatomegaly and gallbladder wall thickening were present in 14 cases (87.5%, 14/16). Periportal high intensity on T2-weighted images was present in 6 cases (75%, 6/8). Normal liver parenchymal enhancement surrounding the main hepatic vein forming a clover-like sign was observed in 4 cases (25%, 4/16). The extent of patchy liver enhancement was statistically associated with clinical severity classification (kappa = 0.565).

Conclusion

Ascites, patchy liver enhancement, and the main hepatic veins narrowing were the most frequent signs of herbal medicine induced HSOS. The grade of abnormal patchy liver enhancement was associated with the clinical severity.     

黄色肉芽肿性胆囊炎的影像诊断与鉴别

目的:分析探讨黄色肉芽肿性胆囊炎的CT和MRI表现特点,提高鉴别诊断能力。方法:收集经临床/手术病理证实为XGO的23例临床及影像资料,分析其CT和MRI影像表现。结果:主要影像表现包括:23例胆囊不同程度增大;胆囊壁弥漫性(18例)或局限性(5例)增厚;胆囊壁内低密度结节15例;增强后胆囊黏膜线样强化13例;胆囊内合并结石12例。结论:CT和MRI可以显示XGO的相关影像特征,对本病的诊断和鉴别提供依据。     

Chronic hepatitis: correlation of early patchy and late linear enhancement patterns on gadolinium-enhanced MR images with histopathology initial experience

The purposes of our study were to describe the early and late enhancement patterns of the liver on gadolinium-enhanced dynamic magnetic resonance (MR) images in patients with chronic hepatitis and to correlate these findings with histopathology. Patients were entered into the study based on the presence of chronic hepatitis, imaging evaluation with MR imaging (MRI), including early and late postgadolinium images, and histopathologic correlation. Early and late dynamic postgadolinium MR images of 29 consecutive patients with a pathologically proven diagnosis of chronic hepatitis were retrospectively evaluated for the presence of three types of enhancement, i.e., homogeneous, linear, and patchy. Correlation was made between the enhancement patterns on MR images and blinded retrospective interpretation of the histopathologic specimens, which were obtained within 3 months of the MR examination. Of the 29 patients, 16 (55.2%) patients showed patchy enhancement on the early gadolinium-enhanced MR images. In 11 (68.8%) of these 16 patients, histopathology demonstrated numerous macrophages, variable hepatocyte necrosis, and increased steatosis. The remaining 13 (44.8%) patients showed homogeneous enhancement on the early gadolinium-enhanced MR images. In 11 (84.6%) of these 13 patients, histopathology demonstrated few or no macrophages, little or no hepatocellular necrosis, and little or no steatosis. The correlation between patchy enhancement and acute liver inflammation was significant (P = 0.005). On the late gadolinium-enhanced MR images, 20 (69.0%) of 29 patients showed prominent linear enhancement. In 19 (95.0%) of these 20 patients, histopathology revealed hepatic fibrosis. We concluded that in patients with chronic hepatitis, the presence of early patchy enhancement indicates either concurrent or recent hepatocellular damage, whereas the presence of late linear enhancement indicates the presence of fibrosis, with a high degree of correlation with histopathologic findings.     

Contrast enhanced sonography of the gallbladder: A tool in the diagnosis of cholecystitis?

RATIONALE AND OBJECTIVES: To evaluate if contrast enhanced sonography (CES) can help to detect gallbladder inflammation and differentiate between acute and chronic cholecystitis. MATERIALS AND METHODS: Thirty-three patients with clinical suspicion of acute cholecystitis were examined with CES before cholecystectomy. Thirty patients with no history of gallbladder disease served as control. CES was performed using 2.5 mL SonoVue. A small mechanical index was chosen (0.1). The enhancement pattern of the gallbladder was ranked in a three-point scale: no enhancement, low enhancement and strong enhancement. 28/33 patients underwent surgery. Sonographic findings were compared to histological results. RESULTS: In 16/20 cases with histological proven acute cholecystitis, the gallbladder wall showed a strong enhancement. Low enhancement was found in four patients with acute and in six patients with chronic cholecystitis. The gallbladder wall of two patients with chronic inflammation and all patients (30/30) of the control group showed no enhancement. CONCLUSION: CES is a feasible tool for detecting gallbladder inflammation. Differentiating between acute and chronic cholecystitis seems to be possible.     

Gallbladder Tuberculosis: CT Findings with Histopathologic Correlation

Objective

We wanted to describe the computed tomography (CT) findings of gallbladder tuberculosis (TB) and to correlate them with pathologic findings.

Materials and Methods

There were seven patients (M:F = 3:4; mean age, 46.3 years; age range, 32 to 78 years) in whom gallbladder TB was eventually diagnosed. All of them underwent cross-sectional imaging with CT, a pathologic examination and a retrospective review. CT imaging evaluation was done in each case, including the findings of a mass versus nodule, wall thickening (uniform or irregular) and the enhancement patterns (homogeneous or heterogeneous).

Results

All the cases of gallbladder TB revealed the following three different CT findings: micronodular lesion of the gallbladder wall (n = 1), a thickened wall (n = 4) and a gallbladder mass (n = 2). There were three cases of homogeneous enhancement of the lesions, including homogeneous enhancement with nodular lesion, homogeneous uniform thickness enhancement and homogeneous thickness enhancement in one case each, and these cases pathology showed tuberculous granuloma with a little caseating necrosis in one case and tuberculous granuloma with rich fibrous tissue, but little or no evident caseating necrosis in two cases. Four cases of heterogeneous enhancement of the lesions, including heterogeneous uniform-thickness enhancement in two cases, heterogeneous enhancement with a local mass lesion in one case and heterogeneous enhancement with a mass that replaced the gallbladder in one case; in these cases, pathology showed tuberculous granuloma with marked caseation or liquefaction necrosis in three cases and tuberculous granuloma by fibrous and calcifications accompanied by caseating necrosis in one case. Among the seven cases of gallbladder TB, six cases were accompanied by abdominal extra-gallbladder TB, including abdominal lymph node TB in five cases and hepatic TB in four cases.

Conclusion

Gallbladder TB has various CT manifestations, and the enhanced CT findings are well matched with pathological features. An irregularly thickened gallbladder wall or a gallbladder wall mass with multiple-focus necrosis or calcifications accompanied by the typical CT findings of abdominal extra-gallbladder TB should suggest the diagnosis of gallbladder TB.     

胆囊病变CT误诊原因分析(附17例报告)

目的:探讨胆囊病变(主要是胆囊癌)的CT误诊原因,以提高胆囊病变的CT鉴别诊断价值。方法:搜集17 例CT漏诊和误诊为胆囊癌的病例,回顾性分析其CT表现和误诊原因。结果:17例CT误、漏诊的胆囊病变中,12例为 原发性胆囊癌,CT误诊为其它病变;5例为其它病变,CT误诊为胆囊癌。误诊的原因:①早期胆囊病变CT上发现困难; ②CT扫描显示胆囊底部结构不满意,对此处病变易遗漏;③胆囊癌常合并存在胆囊结石及胆囊其它病变(胆囊萎缩、胆囊 积液等),当肿瘤组织较小时易被忽略;④晚期胆囊癌侵及肝脏时,不易与晚期肝癌侵犯胆囊相鉴别;⑤CT扫描间距过大 或增强效果不佳等技术因素也可造成误诊。结论:只要检查全面(增强与薄层扫描)、观察仔细,胆囊癌的CT误诊率应能 减少。     

Ablation of the cystic duct and gallbladder: clinical observations

The cystic duct and gallbladder were ablated in eight patients with acute gallbladder disease who had been treated with minicholecystostomy instead of cholecystectomy because of multiple risk factors. First, endoluminal transcatheter radio-frequency electrocoagulation of the cystic duct was performed under fluoroscopic control, which resulted in complete occlusion in all eight patients. Next, the mucosa of the isolated gallbladder was sclerosed with 95% ethanol and 3% sodium tetradecyl sulfate in one to four sessions; no analgesics were required. The gallbladder volumes of all patients, estimated by means of ultrasound, were 1.5-22 cm3 (average, less than 10 cm3) after a mean follow-up period of 5 months. One patient died of a cerebrovascular accident 15 months after sclerotherapy. In all surviving patients, the gallbladder fistulas are dry and obliterated. These early clinical data indicate that electrocoagulation permits reliable, safe obliteration of the human cystic duct. The authors believe that sclerotherapy of the isolated gallbladder is feasible without toxic effects but that their treatment needs adjustment to achieve complete ablation of the gallbladder mucosa in a shorter period and in all patients.     

A new method for thermocholecystectomy. Initial experience and comparison with other techniques.

RATIONALE AND OBJECTIVES. The authors tested the feasibility of thermocholecystectomy for gallbladder ablation in an animal model. METHODS. Thermal treatment of the cystic duct followed by heating of the saline-filled gallbladder using a separately designed heater/expander was performed in 13 pigs (group I). In four animals, heating of the gallbladder alone was performed (group II). Two animals served as controls (group III). All animals were killed 12 weeks after treatment. RESULTS. There was cystic duct occlusion in 10 (77%) of 13 of group I animals. In 6 (60%) of 10 of these animals with cystic duct occlusion, there was complete ablation of the gallbladder mucosa and complete obliteration of the gallbladder lumen. In group II animals, all cystic ducts were intact with an unchanged gallbladder volume in all four animals (100%), and normal gallbladder mucosa were intact in three (75%) of four animals. The gallbladders and cystic ducts in group III animals were normal. CONCLUSIONS. This study demonstrates many technical difficulties with thermal cholecystectomy. However, under ideal conditions, permanent gallbladder ablation is feasible in our animal model using a specially designed heating system.     

胆结石与胆道幽门螺旋杆菌的相关性研究

目的探讨胆道幽门螺杆菌与胆结石的相关性。方法收集38例胆结石患者的胆囊粘膜、胆汁、结石标本（实验组）和20例非结石患者的胆囊粘膜、胆汁标本（对照组）。采用酶联免疫吸附试验{EHSA）、免疫组织化学技术分别对两组患者的胆汁、结石和胆囊粘膜中的幽门螺旋杆菌进行检测。结果实验组胆囊粘膜、胆汁、结石幽门螺杆菌检测阳性率分别为15．9％、81．2％、60．0％;对照组胆囊粘膜、胆汁幽门螺杆菌检测阳性率分别为25．0％、52．9％：实验组与对照组之间胆汁幽门螺杆菌阳性率分别为81．2％、52．9％,差异有统计学意义。结论胆结石患者胆道系统中存在幽门螺杆菌感染,幽门螺杆菌可能与胆结石的形成有关。     

Gallbladder ablation through radiologic intervention: an experimental alternative to cholecystectomy

Twenty pigs underwent (a) cystic duct occlusion by means of fluoroscopically guided transcatheter endoluminal bipolar radio-frequency (RF) electrocoagulation and (b) gallbladder sclerotherapy with one of two different regimens of ethanol and sodium tetradecyl-sulfate (STS). Serum ethanol levels and hepatic enzyme tests showed no acute toxicity. Postmortem histologic studies showed that the bile ducts beyond the occlusion site remained entirely unaffected in all animals. In three of four animals followed up for 2 weeks, the sclerosants induced necrosis of the gallbladder mucosa, but the adjacent liver, serosa, and blood vessels remained intact. In 13 of 16 animals followed up for 8 weeks, the gallbladder lumen was obliterated by fibrous scar tissue. In the animals treated with 95% ethanol and 3% STS, the gallbladder mucosa was necrotic in all areas after 2 weeks (two of two animals) and eradicated completely after 8 weeks (six of eight animals); the other regimen (70% ethanol plus 1% STS) was somewhat less effective. In this study, the combination of RF-mediated cystic duct occlusion and gallbladder sclerotherapy with ethanol and STS permitted gallbladder ablation in swine without toxic side effects.     

Percutaneous gallstone lithotripsy. Results in acute and chronic swine models

The authors describe here a rotary catheter for the percutaneous fragmentation of gallstones. Gallstones are drawn into the rotating impeller by a powerful vortex and mechanically fragmented. Fragments are aspirated from the gallbladder following use of the device. The safety and efficacy of the device was tested after placement of human gallstones in the pig's gallbladder in 19 acute, 15 chronic, and two control experiments. In 27 completed experiments, 206 human gallstones (6-20 mm) were implanted. Most residual fragments were less than 2 mm; 24 fragments were 2 to 4 mm and seven were 5 to 8 mm. Acute histologic changes included focal loss of mucosa, mucosal and submucosal hemorrhage, and deposition of biliary material in the mucosa and submucosa. At 30 and 90 days, gallbladder histology revealed regeneration of the mucosa with isolated granuloma formation.     

左肾上腺巨大海绵状血管瘤1例CT评价及文献复习

目的研究肾上腺海绵状血管瘤CT表现的动态变化。方法 1例经手术病理证实的左侧肾上腺巨大海绵状血管瘤患者术前接受了CT三期动态增强扫描,对其CT表现结合文献复习进行了回顾性分析。结果 CT平扫显示左肾上腺区有一大小约12cm×11cm×9cm的等低混杂密度肿块,边界清楚,肿块内有斑片状及条带状钙化影。增强扫描后,肿块呈明显不均匀强化,于动脉期肿块边缘有斑片状明显强化灶,于静脉期及延迟期强化灶逐渐向中心扩大。结论肾上腺海绵状血管瘤在三期动态增强扫描中具有特征性表现,有助于其明确诊断。     

Percutaneous chemical gallbladder sclerosis after laser-induced cystic duct obliteration: results in an experimental model.

OBJECTIVE. Chemical gallbladder sclerosis has been attempted as a way to defunctionalize the gallbladder in patients who have undergone nonsurgical removal of gallstones and who are unable to undergo surgical/laparoscopic cholecystectomy. The purpose of this investigation was threefold: to study an animal model for chemical sclerosis of the gallbladder with 95% ethanol and 3% sodium tetradecyl sulfate, to attempt chemical sclerosis immediately after percutaneous cystic duct obliteration by laser thermocoagulation, and to assess histopathologic changes in the gallbladder after sclerosis. MATERIALS AND METHODS. Percutaneous cholecystostomy and laser thermocoagulation of the cystic duct was performed in 13 pigs. Eight pigs underwent immediate gallbladder sclerosis with 95% ethanol and 3% sodium tetradecyl sulfate while two pigs received 95% ethanol only. The remaining three pigs served as controls. The cholecystostomy catheter was removed immediately after the procedure. All animals were sacrificed 6 weeks after laser thermocoagulation. Multiple sections through the gallbladder, which included the adjacent liver, the cystic duct, and the common bile duct, were obtained for histologic examination. RESULTS. At autopsy, the gallbladder in all 10 animals who underwent gallbladder sclerosis was reduced in size compared with controls. In all treated animals, the gallbladder mucosa was denuded; however, in nine of 10 cases reepithelialization had occurred. Complete sclerosis without reepithelialization was achieved in one pig who received both ethanol and sodium tetradecyl sulfate. In the two animals who received ethanol only, the depth of wall necrosis around the gallbladder lumen was less than in those pigs who received both ethanol and sodium tetradecyl sulfate. No pigs showed signs of hepatic necrosis or injury to the common bile duct. CONCLUSION. Cystic duct laser thermocoagulation allows immediate gallbladder sclerotherapy without injury to the common bile duct. Sclerosis with ethanol and sodium tetradecyl sulfate results in denudation of the gallbladder mucosa. However, a single therapeutic session with immediate removal of the cholecystostomy catheter was inadequate for gallbladder ablation in this model because of reepithelialization.     

黄色肉芽肿性胆囊炎的影像学表现

目的：探讨黄色肉芽肿性胆囊炎（XGC）的CT和MRI表现。方法：回顾性分析8例经手术病理证实的XGC,总结其CT和MRI表现。结果：术前诊断为XGC2例,误诊为胆囊癌6例。CT表现：8例均有胆囊壁增厚,其中局限性增厚表现为动脉期环形强化1例,弥漫性增厚表现为夹心饼干征3例,4例表现为胆囊黏膜线完整;伴胆囊结石5例,胆总管结石1例,右肝内胆管细胞癌1例。MRI表现：3例T2WI表现为胆囊壁内高信号结节,2例门脉期及延迟期清晰显示明显强化的完整的胆囊黏膜线。结论：CT增强扫描表现环形强化和夹心饼干征;MRI扫描T2WI表现为胆囊壁内高信号结节,增强扫描显示明显强化的完整的胆囊黏膜线等表现,是提示XGC诊断的重要征象。     

原发性胆囊癌的临床及CT分析

目的；分析胆囊癌的CT表现及其对临床诊断的价值。方法：本组42例胆囊均有完整的临床、实验室及CT扫描资料并经病理证实。结果：胆囊癌的主要CT表现有：胆囊壁的不规则增厚、胆囊腔内乳头状癌结节、胆囊呈等密度实质性肿块、直接侵犯肝脏、肝门及胰头部位淋巴结转移，增强后，囊壁和囊内的癌结节均被增强。结论：胆囊癌的CT表现对其诊断和鉴别诊断具有重要的价值。     

Cystic duct occlusion and transcatheter sclerosis of the gallbladder in the rabbit

We have identified a reliable sclerosant of the gallbladder in rabbits. After ligating the cystic ducts with a silk ligature in 24 rabbits and aspirating the bile from the gallbladder, we instilled a mixture of 95% ethanol and either 2 M% trifluoroacetic acid (TFA) or 5 M% TFA into the gallbladder. The animals were killed after 6 or 8 weeks. Ethanol with TFA resulted in replacement of gallbladder lumen with fibrous tissue in 22 rabbits. The two sclerosants were equally reliable and produced quantitatively similar fibrosis in the rabbits. The tendency for normal biliary mucosa to repopulate a sclerosed gallbladder can be obviated by complete occlusion of the cystic duct. The parameters for successful transcatheter sclerosis of the gallbladder have now been defined in an animal model.     

Gallbladder varices: imaging findings in patients with portal hypertension

A retrospective review of the medical and imaging records of 50 patients with portal hypertension examined in the authors' department during a 2-year period identified six patients with gallbladder wall varices. Imaging studies performed in these patients included computed tomography (CT) (four patients), duplex and color Doppler flow (five patients), and magnetic resonance (MR) (four patients). Five of six patients with gallbladder varices had portal vein thrombosis. Anechoic areas within the gallbladder wall detected with ultrasonography could be distinguished from intramural edema by using duplex or color Doppler flow imaging in all five patients in whom it was used. Contrast material enhancement of these varices was detected with CT in three patients, two of whom also had adjacent mesenteric collaterals. Gradient-echo MR imaging (fast imaging in steady precession/fast low-angle shot) showed flow-related enhancement within the gallbladder wall in two patients. The presence of gallbladder wall varices may imply the presence of portal vein thrombosis. Since these varices can be a source of major blood loss, surgeons must be made aware of them when operating on patients with portal hypertension.     

Actinomycosis of the Gallbladder Mimicking Carcinoma: a Case Report with US and CT Findings

We describe a case of actinomycosis of the gallbladder mimicking carcinoma. Sonography showed a hypoechoic mass replacing gallbladder lumen and engulfing a stone; contrast-enhanced computed tomography showed a heterogeneously enhanced thickened gallbladder wall with subtle, disrupted luminal surface enhancement, which formed a mass. As a result of the clinical and radiologic presentation, our impression was of gallbladder carcinoma. Actinomycosis should be included in the differential diagnosis when sonography and computed tomography findings show a mass engulfing the stone in the gallbladder and extensive pericholecystic infiltration with extension to neighboring abdominal wall muscle.     

Dynamic MRI of the gallbladder lesions: Differentiation of benign from malignant

Forty-nine pathologically proven gallbladder lesions were evaluated in 45 patients using dynamic MRI with a spoiled gradient pulse sequence (SPGR), to access the ability of this technique to differentiate benign from malignant gallbladder lesions. The studies were reviewed retrospectively. Signal intensity of the lesions were measured. Twenty-one malignant and 28 benign lesions were classified into three categories: polypoid, diffuse wall thickening, and exophytic. Early and delayed enhancement patterns were evaluated. For the polypoid masses, malignant lesions (n = 9) demonstrated early and prolonged enhancements, whereas benign lesions (n = 14) had early enhancement with subsequent washout (P < .05). For diffuse gallbladder wall thickening, malignant lesions (n = 6) demonstrated early and prolonged enhancement and benign lesions (n = 14) showed relatively slow, prolonged enhancement (P < .05). The exophytic masses (n = 6) all were malignant and demonstrated early and prolonged enhancement. Dynamic MRI can help differentiate benign from malignant gallbladder lesions.     

Exercise-induced acute renal failure and patchy renal vasoconstriction: CT and MR findings

Contrast-enhanced CT and MR imaging of the kidney were performed in two patients with acute renal failure and severe loin pain following a track race. Prior to the exercise both patients had had flu-like symptoms and took oral medications. There was no evidence of myoglobinuria. Immediate postcontrast CT of the kidney showed multiple patchy areas of poor contrast enhancement; after 24 h, there were multiple patchy enhancing cortical areas on CT without further use of intravenous contrast media. Magnetic resonance imaging of the kidney showed patchy areas of high signal intensity with obliteration of the corticomedullary contrast on T1-weighted images. On T2-weighted images the signal intensity of the lesion was high in one patient and low in the other.