Therapeutic impact of abdominopelvic computed tomography in patients with acute abdominal symptoms

PURPOSE

To determine the diagnostic and therapeutic impact of abdominopelvic computed tomography (CT) in patients with acute abdominopelvic pain.

MATERIAL AND METHODS

Referring clinicians completed pre-CT and post-CT questionnaires for 50 patients in whom CT had been requested because of acute abdominopelvic pain. Clinicians recorded their leading diagnosis, confidence in this, and intended management. Following CT, clinicians again recorded these responses in the light of CT findings. Responses pre-CT and post-CT were compared in order to determine diagnostic and therapeutic impact.

RESULTS

Diagnostic confidence rose significantly following CT (mean score 6.8 pre-CT versus 8.3 post-CT; P<0.0001). Intended management changed because of CT findings in 29 (58%) patients: 14 (28%) subjects whose intended management was surgical were treated medically and an additional 2 were transferred to gynecological care; 4 patients whose intended management was medical were treated surgically; 2 patients whose intended management was medical were treated by percutaneous drainage; a patient whose intended management was percutaneous drainage was treated by surgery. Of 6 patients with uncertain management pre-CT, 2 were treated surgically and 4 medically. The leading diagnosis also changed as a consequence of CT in 7 (33%) of 21 patients in whom intended management did not alter.

CONCLUSION

CT in patients with acute abdominopelvic pain has considerable diagnostic and therapeutic impact, altering management in 58% of patients studied. The major effect is to avert intended laparotomy.

Local radiological staging of rectal cancer

Rectal cancer is a common malignancy with a highly variable outcome. Local recurrence is dependent upon tumour stage and surgical technique. The role of pre-operative imaging is to determine which patients may be safely managed by surgery alone and which need additional therapy in order to facilitate surgery and improve outcome. This decision depends on the distinction between those with early and advanced disease. While trans-rectal ultrasound has traditionally been used to answer this question, a role for magnetic resonance imaging (MRI) is increasingly argued. This review will focus on the treatment options for rectal cancer and the clinical questions that subsequently arise for the radiologist to answer.

CT colonography practice in the UK: a national survey

AIM

To determine the provision of computed tomography (CT) colonography in UK radiology departments.

MATERIALS AND METHODS

A questionnaire relating to the availability of CT colonography, barriers to implementation, clinical indications, technique, and practitioners was posted to clinical directors of UK radiology departments.

RESULTS

One hundred and thirty-eight departments responded. Fifty (36%) offered CT colonography in day-to-day clinical practice. Of those that did not, 68 of 87 (64%) cited limited scanner capacity as the main barrier. Of the 50 departments offering a service, 39 (78%) offered CT after incomplete colonoscopy, 36 (72%), after failed barium enema, and 37 (74%) as an alternative to barium enema. Of those offering a service, the number of studies performed varied between one per month (38%) to more than one per day (8%). Total experience varied between 20 or fewer studies (28%) to more than 300 (12%). Full bowel preparation was common (92%), as was dual positioning (90%). Colonography was interpreted by radiologists with a subspecialty interest in gastrointestinal imaging in 64% of centres offering a service.

CONCLUSION

CT colonography is widely available in the UK, with approximately one-third of responders offering a service. Experience and throughput varies considerably. Limited CT scanner capacity is the major barrier to further dissemination.

Use of multidetector-row CT colonography for detection of colorectal neoplasia in patients referred via the Department of Health "2-Week-wait" initiative

AIM

Patients referred under the Department of Health 2-week wait initiative with symptoms of colorectal cancer frequently undergo whole-colon examination. We investigated the use of computed tomography (CT) colonography as an alternative to colonoscopy in this scenario.

MATERIALS AND METHODS

Fifty-four consecutive patients, referred via the 2-week wait initiative and scheduled for colonoscopy, consented to undergo multidetector CT colonography immediately before endoscopy. The site and morphology of any polyp or cancer detected by CT was noted and comparison made with subsequent colonoscopy.

RESULTS

Colonoscopy detected polyps or cancer in 29 patients (53.7%). CT colonography prospectively detected 18 of 41 (44%) polyps of 1-5 mm, three of four (75%) polyps of 6-9 mm, four of four (100%) polyps 10 mm or larger, and five of six (83%) cancers. The missed cancer occurred early in the series and was a perceptive error. The overall sensitivity, specificity, positive predictive value and negative predictive value of CT colonography for cancer and polyps 10 mm or greater on a per patient basis were 90, 100, 100 and 98%, respectively. CT detected one renal cancer and one colonic cancer, initially missed due to incomplete colonoscopy.

CONCLUSION

CT colonography is a robust technique for investigation of symptomatic patients. The learning curve must be overcome for optimal performance.

Observer Variation in the Detection of Colorectal Neoplasia on Double-contrast Barium Enema: Implications for Colorectal Cancer Screening and Training

AIM

To assess inter-observer error for the diagnosis of neoplasia on double contrast barium enema (DCBE) in the light of claims that no additional interpretative training would be needed for implementation in a national screening programme.

MATERIALS AND METHODS

10 experts, 10 consultants, and 10 experienced trainees each reported 20 DCBE studies, of which two showed cancer, three showed large polyps, four showed small polyps, and 12 were normal. Inter-observer variation was compared using odds ratios with the trainee group as reference (baseline group).

RESULTS

Experts were significantly more likely to correctly identify neoplasia on DCBE than trainees. The odds of a correct diagnosis for experts were 2.79 (95% CI 2.04, 3.81) for cancer, 2.36 (1.88, 2.97) for large polyps, and 3.50 (1.98, 6.18) for small polyps. While consultants were more likely to correctly diagnose a large polyp than trainees, 1.45 (1.15, 1.84), there was no significant difference between these two groups for the correct diagnosis of either cancer, 1.24 (0.52, 2.96), or small polyps, 1.26 (0.83, 1.90). A cancer was missed by 6 (60%) experts, 9 (90%) consultants, and 8 (80%) trainees. Large polyps were missed by 4 (40%) experts, 5 (50%) consultants, and 6 (60%) trainees. There was no significant difference between any group when false positive diagnoses were considered.

CONCLUSIONS

There is considerable inter-observer perceptive error for the diagnosis of neoplasia on DCBE. Experts performed significantly better than other observers but the overall standard of performance was poor, even amongst experts.

Childhood emotional abuse and neglect as predictors of psychological and physical symptoms in women presenting to a primary care practice

OBJECTIVE

There were two aims to this study: first to examine whether emotional abuse and neglect are significant predictors of psychological and somatic symptoms, and lifetime trauma exposure in women presenting to a primary care practice, and second to examine the strength of these relationships after controlling for the effects of other types of childhood abuse and trauma.

METHOD

Two-hundred and five women completed the Childhood Trauma Questionnaire (Bernstein et al., 1994), Trauma History Questionnaire (Green, 1996), the Symptom Checklist-revised (Derogatis, 1997), and the Revised Civilian Mississippi Scale for posttraumatic stress disorder (Norris & Perilla, 1996) when presenting to their primary care physician for a visit. Hierarchical multiple regression analyses were conducted to examine unique contributions of emotional abuse and neglect variables on symptom measures while controlling for childhood sexual and physical abuse and lifetime trauma exposure.

RESULTS

A history of emotional abuse and neglect was associated with increased anxiety, depression, posttraumatic stress and physical symptoms, as well as lifetime trauma exposure. Physical and sexual abuse and lifetime trauma were also significant predictors of physical and psychological symptoms. Hierarchical multiple regressions demonstrated that emotional abuse and neglect predicted symptomatology in these women even when controlling for other types of abuse and lifetime trauma exposure.

CONCLUSIONS

Long-standing behavioral consequences may arise as a result of childhood emotional abuse and neglect, specifically, poorer emotional and physical functioning, and vulnerability to further trauma exposure.

Potential clinical implications of direction of a trans-sphincteric anal fistula track

Background

The longitudinal direction of a trans-sphincteric anal fistula track through the anal sphincter complex may have implications regarding fistulotomy.

Methods

The angle of the track of trans-sphincteric fistulas relative to the longitudinal axis of the anal canal was measured before operation by means of magnetic resonance imaging (MRI) in 46 patients. This was compared with the findings at operation.

Results

The track passed cranially as well as laterally at an acute angle (less than 90°) in 23 patients while it passed either transversely or caudally at an obtuse angle (90° or more) in the remaining 23. The internal opening was significantly higher in relation to the dentate line (above in eight patients, at the dentate line in 14 and below in one patient) when the track was acute than when it was obtuse (above in one, at the dentate line in 17 and below in five patients) (P = 0·004). The fistula track crossed the sphincter at a median angle of 35°, 95° and 132° from internal openings sited above, at and below dentate line level respectively (P = 0·002).

Conclusion

Fistula tracks passed cranially and laterally through the sphincter complex in half of these patients, and were most acutely angled on MRI when internal openings were situated above the dentate line. Preoperative MRI might alert surgeons to the potential hazard of fistulotomy being more extensive than anticipated from simple palpation of the level of the internal opening.

Use of multidetector-row computed tomographic colonography before flexible sigmoidoscopy in the investigation of rectal bleeding

Selective colonography may reduce need for colonoscopy

Optimizing bowel preparation for multidetector row CT colonography: effect of Citramag and Picolax

AIM

To compare the adequacy and acceptability of Picolax and Citramag bowel cleansing agents for CT colonography.

MATERIALS AND METHODS

Multidetector row CT colonography was performed in 124 subjects; 43 had been prepared with Picolax and 81 with Citramag. Datasets were assessed for retained fluid and solid residue, and overall adequacy of segmental visualization. Preparation acceptability was also assessed.

RESULTS

There was significantly less retained fluid with Picolax. The odds of being in the next higher category for retained fluid when using Picolax were 0.33 (CI: 0.22-0.50, p<0.0001) when compared with Citramag, for all segments combined. However there was significantly more retained solid residue with Picolax. The odds of being in the next higher category for retained residue when using Picolax were 2.44 (CI: 1.41-4.24, p=0.002) when compared with Citramag, for all segments combined. There was no significant difference with respect to overall segmental visualization: the odds of a segment being adequately visualized when using Picolax were 1.52 (CI: 0.88-2.65, p=0.14) when compared with Citramag. There was no significant difference with respect to acceptability.

CONCLUSION

Picolax results in a significantly drier colon than Citramag and associated with more retained residue. We found Picolax the more suitable preparation for CT colonography.

Magnetic resonance imaging for primary fistula in ano

BACKGROUND

This was a prospective study designed to determine the therapeutic impact of magnetic resonance imaging (MRI) in primary fistula in ano, and to assess its effect on outcome.

METHODS

Thirty patients with suspected primary fistula in ano underwent preoperative MRI, and the findings were revealed during surgery following examination under anaesthesia (EUA). Any effect on operative approach was noted. Outcome was assessed at a median of 12 months.

RESULTS

Two patients had sinuses, one had no sepsis and 27 had fistulas: five superficial, seven intersphincteric, 14 trans-sphincteric and one suprasphincteric. MRI and EUA agreed in 15 patients and MRI findings altered the surgical approach in a further three (10 per cent); two of the latter patients were believed to have a sinus at EUA, which MRI correctly identified as a fistula, allowing definitive treatment. The therapeutic impact of MRI was therefore 10 per cent. Persisting disagreement between MRI and EUA in 12 patients mostly related to minor discrepancies in classification. Only one patient required further unplanned surgery, which was for skin-bridging rather than any new sepsis.

CONCLUSION

In experienced hands, MRI has a therapeutic impact of 10 per cent for primary fistula in ano, precipitating surgery that is likely to reduce recurrence in a small, but important, proportion of patients.

Transvaginal power Doppler ultrasound in pelvic congestion

PURPOSE

Pelvic congestion is diagnosed by transuterine venography, an invasive procedure requiring sedation and irradiation. Ultrasound may be an alternative but is hindered by slow flow within pelvic veins. In an attempt to counter this, we investigated the possible role of transvaginal power Doppler ultrasound.

MATERIAL AND METHODS

42 women with a clinical suspicion of pelvic congestion underwent transvaginal ultrasound. Adnexal veins were examined and a congestion score established. Planimetric measurements of adnexal vessels were obtained using power Doppler ultrasound, and uterine and ovarian morphology noted. All women then underwent transuterine venography and agreement with the ultrasound congestion score and morphologic features was determined.

RESULTS

There was a trend towards weak positive correlation between ultrasound and venography congestion scores (r = 0.29, p = 0.06). However, agreement between scores was poor on an individual basis (95% limits of agreement, -3.9 to +2.7). Planimetric power Doppler assessments of adnexal vascularity were unrelated to venographic congestion. Instead, there was correlation between the number and diameter of ovarian follicles and venographic congestion: women with congestion tended to have significantly more (0.04) and smaller follicles (p = 0.001).

CONCLUSION

There was poor individual agreement between ultrasound and venographic estimates of congestion. However, there was a direct relationship between venographic congestion score and ovarian morphology.

CT colonography: methods, pathology and pitfalls

Computed tomography colonography (CTC) is a relatively new technique that is currently challenging more established methods of large bowel imaging. Several workers have suggested CTC surpasses the barium enema and approaches conventional endoscopy for detection of colorectal neoplasia. Accurate diagnosis relies on technically good studies, the main aim of which is adequate bowel cleansing and distension. Furthermore, the learning curve is steep and normal colonic anatomy has to be re-learned in a CT context. This review aims to describe the technique, revise the imaging features of both normal and pathological colon, and to highlight potential diagnostic pitfalls and their avoidance.

Response of fistulating Crohn's disease to infliximab treatment assessed by magnetic resonance imaging

AIMS

To assess fistula track healing after infliximab treatment using magnetic resonance imaging.

METHODS

Magnetic resonance imaging and clinical evaluation were performed before and after three infliximab infusions given over a 6-week period. Magnetic resonance images were evaluated for abscesses and fistula tracks. Paired magnetic resonance image examinations were rated 'better', 'unchanged' or 'worse'. Magnetic resonance imaging and clinical outcomes were then compared.

RESULTS

Of the 12 referred patients, pre-treatment magnetic resonance imaging detected abscesses in three (two not treated). Of the 10 treated patients, seven had peri-anal fistulas, two of whom also had recto-vaginal fistulas, and three had abdominal wall entero-cutaneous fistulas. After infliximab, four were in remission, one had a response and five were non-responders. One developed a peri-anal abscess. Magnetic resonance imaging improved in six, was unchanged in two and was worse in two. In four of the six with improvement in magnetic resonance imaging, the fistula track resolved, but two of these had clinically persistent entero-cutaneous fistulas. The clinical outcome and magnetic resonance imaging correlated in seven of the 10 patients; in three (two entero-cutaneous and one peri-anal), there was discordance.

CONCLUSIONS

Magnetic resonance imaging identifies clinically silent sepsis. Fistulas may persist despite clinical remission. Clinical response to infliximab and clinical correlation with magnetic resonance imaging were poor in patients with abdominal entero-cutaneous fistulas.

[Endoanal MR imaging: diagnostic assessment]

Endoanal MR imaging is an alternative to anal endosonography for the acquisition of high-resolution images of the external and internal anal sphincter. A dedicated anal receiver coil is placed in the anus so that it spans the sphincter complex. Highly detailed images of the sphincters can be obtained in any plane and the morphological abnormalities found in various types of anal incontinence can be demonstrated. Whilst MR demonstrates external sphincter disruption with an efficacy similar to that of endosonography, it is better able to demonstrate external sphincter atrophy that is presumed secondary to neuropathy. The finding of coexisting muscular atrophy on MR may prejudice the effects of anal sphincter repair for obstetric disruption.

Predictive value of internal anal sphincter thickness for diagnosis of rectal intussusception in patients with solitary rectal ulcer syndrome

BACKGROUND

The aim of this study was to determine any association between a thickened internal anal sphincter (IAS) on anal endosonography and high-grade rectal intussusception on evacuation proctography in patients with solitary rectal ulcer syndrome.

METHODS

Anal endosonography was performed in 20 patients with solitary rectal ulcer syndrome and IAS thickness defined as normal or abnormal depending on age. Sphincter thickness was compared with the presence or absence of high-grade intussusception on subsequent evacuation proctography to determine any relationship between the two.

RESULTS

Thirteen patients had an abnormally thick IAS, two of whom were unable to evacuate. Of the remaining 11 patients, ten showed high-grade intussusception (positive predictive value 91 per cent). Only three of seven patients with a normal IAS had high-grade intussusception (negative predictive value 57 per cent). Patients with a thick IAS were significantly more likely to have proctographic evidence of high-grade intussusception (P = 0.047).

CONCLUSION

Sonographic findings of a thick IAS are highly predictive for high-grade rectal intussusception in patients with solitary rectal ulcer syndrome.

Alteration of anal sphincter morphology following vaginal delivery revealed by multiplanar anal endosonography

OBJECTIVE

To assess morphologic change in the anal sphincters in the absence of endosonographic evidence of trauma after vaginal delivery.

DESIGN

Prospective observational study.

SETTING

District general hospital.

POPULATION

Consecutively booked nulliparous pregnant women attending antenatal clinic.

METHODS

All women were examined using three-dimensional anal endosonography, simple manometry and had questionnaire assessment of incontinence before and after delivery.

MAIN OUTCOME MEASURES

Components of the anal canal were measured in the axial, sagittal and coronal planes and paired pre- and post-delivery examinations were compared. Any changes were related to changes in continence and anal canal manometry.

RESULTS

Twenty-two women had a vaginal delivery and no endosonographic evidence of perineal trauma after delivery. After delivery, there was significant shortening of the length of the anterior external anal sphincter [EAS] (mean 21.7 vs 20.5 mm, P = 0.02) when measured in the sagittal plane, which increased in anterior angulation with respect to the axis of the anal canal (10 degrees vs 13.8 degrees, P = 0.03). In the axial plane, no change was seen in the thickness of any of the sphincter components after delivery. None of these morphologic changes correlated with changes in manometry or continence score.

CONCLUSIONS

Anal sphincter morphology changes after an otherwise atraumatic vaginal delivery. This change does not correlate with any functional symptoms.

Tailgut cyst associated with a pilonidal sinus: an unusual case and a review

Tailgut cysts are rare congenital abnormalities in the retrocaecal/presacral region. Clinical diagnosis is difficult and delayed and they can present in childhood and adult life with a variety of clinical symptoms and complications. Differential diagnoses include, rectal duplication cysts, cystic teratoma, epidermal cyst, anal gland cyst and anal gland carcinoma. Magnetic resonance imaging has recently become the modality of choice to image these cysts. Although Tailgut cysts rarely undergo malignant transformation, early surgical resection is presently considered the treatment of choice. Here we report the case of a 34 year old gentleman with a Tailgut cyst associated with a Pilonidal sinus, and review of the literature. We believe that the high incidence of complications associated with operations in the presacral region should be weighed against the generally benign course of these lesions, especially with the quality of modern imaging technology.

The therapeutic impact of abdominal ultrasound in patients with acute abdominal symptoms

AIM

The technical performance of abdominal ultrasound in the investigation of acute abdominal pain has been thoroughly investigated but its therapeutic effects are less well understood. We aimed to determine the therapeutic effect of abdominal ultrasound in the investigation of acute abdominal pain.

MATERIAL AND METHODS

A pre- and post-intervention observational study design was used to determine the diagnostic and therapeutic effects of abdominal ultrasound for acute abdominal pain. Referring clinicians completed a pre-ultrasound questionnaire that detailed their leading diagnosis, confidence in this and intended management in 100 consecutive adult patients. Following ultrasound a second questionnaire was completed. This again detailed the leading diagnosis, confidence in this and their intended management. Clinicians quantified the management contribution of ultrasound both for the individual case in question and in their clinical experience generally.

RESULTS

The leading diagnosis was either confirmed or rejected in 72 patients and a new diagnosis provided where no prior differential diagnosis existed in 10. Diagnostic confidence increased significantly following ultrasound (mean score 6.5 pre-ultrasound vs 7.6 post-ultrasound, P < 0.001). Intended management changed following ultrasound in 22 patients; 15 intended laparotomies were halted and a further seven patients underwent surgery where this was not originally intended. Ultrasound was rated either 'very' or 'moderately' helpful in 87% of patients, with 99% of clinicians finding it either 'very' or 'moderately' helpful generally.

CONCLUSION

Abdominal ultrasound has considerable diagnostic and therapeutic effect in the setting of acute abdominal pain.