Nebulization of pharmacological solutions with an innovative medical device based on microvaporization

The currently available nebulization devices have a slow aerosol flow and produce vapor with large microdrops. Improved devices that achieve higher airflow and produce smaller microdrops are needed to improve the clinical care of patients. To address this critical need, we developed a novel system for the molecular vaporization of liquids. This device vaporizes an active pharmacological substance dissolved in water, alcohol, or a mixture of water and alcohol using two energy sources at the same time: high-frequency ultrasound and thermal induction. Application of energy to a solution contained in the device's tank allows, within tens of seconds, for the vaporization of the solution itself, with the generation of a vapor consisting of microdrops of very small diameter (0.2-0.3 μm). In this article, we illustrate the technology used, the main verification tests performed, and the primary fields of application for this device. In particular, the advantages of both the aerosol delivery system and the administration system are highlighted.

Large retroperitoneal sarcoma invading the inferior vena cava successfully resected. Technical notes of two cases

Retroperitoneal sarcomas are rare neoplasms . They frequently reach a very large size and invade adjacent organs before they are detected. Involvent of the inferior vena cava is uncommon. Distant metastases are a late feature. The mainstay of treatment is compartmental resection and contiguous organ resection. We report two cases of right-sided massive primary retroperitoneal leiomyosarcoma in pauci symptomatic women. In both cases treatment consisted of radical surgery. En bloc resection of the tumor and surrounding tissues and organs as well as part of the right wall of the subrenal IVC. To close the wall defect direct suture repair was used resulting in a reduced caliber but no hemodynamic sequelae or endoluminal thrombi. All the resection margins, including the inferior vena cava wall, were negative. The postoperative course was unremarkable and caval blood flow was optimal. The current gold standard treatment for retroperitoneal sarcoma is en bloc multivisceral resectionresection. KEY WORDS: Peritoneal sarcoma, Surgery, Vena cava.

PET/CT in congenital hyperinsulinism: transforming patient's lives by molecular hybrid imaging

Congenital hyperinsulinism (HI) is a life-threatening condition characterized by severe and recurrent episodes of hypoglycaemia due to defects in key genes involved in regulating insulin secretion. The delay in diagnosis and inappropriate management of HI lead to high risk of permanent hypoglycemic brain injury. The management of HI is challenging as each form of HI (focal, diffuse, and atypical) requires its own therapeutic strategy. In HI diagnostic work-up, integrated PET/CT scan is currently the first-line imaging technique allowing to differentiate between diffuse and focal form and, in the latter case, to localize the focus within the pancreas with high precision. Only in focal HI partial pancreatectomy is the treatment of choice and a curative surgical treatment means a real chance of transforming patient's lives and HI patient's future. The aim of this review is to discuss the role of PET/CT imaging in HI scenario, its technical advantages and limitations and how successful surgery is strongly dependent on accurate preoperative assessment (genetic analysis and PET/CT scan). A multidisciplinary approach in HI diagnosis and treatment inside a single team (involving different expertise) allows to manage children safely and properly, supporting their families in an organized care network.

Imaging of primary retroperitoneal neoplasms

Retroperitoneal soft tissue tumors are frequently incidental findings on imaging tests as Computed tomography (CT) or Magnetic Resonance Imaging (MRI). Retroperitoneal soft tissue tumors are rare and therefore not common in daily radiological practice. Clinician and radiologist'skills to set retroperitoneal soft tissue tumors at presentation is crucial for a correct patient management. So far, several diagnostic algorithms have been proposed to assess retroperitoneal masses, which have not been validated by case histories (2-5). The aim of this article is to evaluate a new classification of retroperitoneal masses using CT and MRI. KEY WORDS: CT, Diagnosis, MRI, Retroperitoneum, Soft tissue sarcoma.

Clinical application of 18F-DOPA PET/TC in pediatric patients

The use ¹⁸F-DOPA PET/CT for oncologic and non-oncologic pediatric diseases is well consolidated in clinical practice. The indications include brain tumors, neuroendocrine malignancies and congenital hyperinsulinism. The number of papers involving pediatric subjects is steadily growing. However, literature still lacks clinical trials and large multicentric studies in contrast with the extensive literature available for adult patients. The aim of this review is to discuss the main clinical indications of ¹⁸F-DOPA in pediatric oncologic and nononcologic diseases and to analyze its role in diagnosis, staging, biopsy and surgical planning. The high resolution of PET/CT tomographs in addition to the high sensitivity and specificity of ¹⁸F-DOPA imaging exceeds the downsides linked to this nuclear medicine imaging modality. In fact, few potential limitations could discourage the use of PET/CT imaging. For example, similarly to MRI studies the long acquisition time of a PET/CT scan often requires sedation especially in infants. Moreover, the radiation exposure of a PET/CT scan may be high, but the clinical benefit deriving from nuclear medicine imaging outruns the risk connected to the use of ionizing radiations.

Seminal Vesicle Urinary Reflux After TURP Mimicking Vesicular Invasion From Prostate Cancer on 18F-Choline PET/CT

Seminal vesicles are paired secretory glands located posterior to the bladder in men that produce seminal fluid to maintain sperm. Seminal vesicle reflux into the prostatic ducts may be associated with prostatitis in older patients or may represent a very rare complication of transurethral prostate resection in patients with prostatic cancer. This condition is frequently accidentally diagnosed on excretory urography and/or retrograde urethrogram. Clinical presentation includes pain, fever, recurrent epididymitis-prostatitis, and post void dribbling.

PET/CT in pediatric oncology

The use of PET/CT in adult oncology has been consolidated by several and authoritative multicentric studies, metanalyses and systematic reviews. International guidelines help everyday nuclear medicine specialists, oncologists and radiologists in choosing the most suitable diagnostic path for each patient. Classifications based on traditional imaging and PET/CT findings define the most appropriate treatment and can predict the outcome for different types of malignancies. However, compared to adult patients the use of PET/CT in pediatric oncology is often burdened by lack of systematic and large multicentric studies and consequently accurate and precise guidelines. The cause of this shortage of large trials may be attributed to the rarity of these neoplasms and to the fear of long-term radiation effects on this peculiar category of patients. The aim of this article is to review the applications of PET/CT for imaging the most common pediatric neoplasms.

Differences between computed tomoghaphy and surgical findings in acute complicated diverticulitis

BACKGROUND/OBJECTIVE

A preoperative reliable classification system between clinical and computed tomography (CT) findings to better plan surgery in acute complicated diverticulitis (ACD) is lacking. We studied the inter-observer agreement of CT scan data and their concordance with the preoperative clinical findings and the adherence with the intraoperative status using a new classification of diverticular disease (CDD).

METHODS

152 patients operated on for acute complicated diverticulitis (ACD) were retrospectively enrolled. All patients were studied with CT scan within 24 h before surgery and CT images were blinded reanalyzed by 2 couples of radiologists (A/B). Kappa value evaluated the inter-observer agreement between radiologists and the concordance between CDD, preoperative clinical findings and findings at operation. Univariate and multivariate analysis were used to evaluate the predicting values of CT classification and CDD stage at surgery on postoperative outcomes.

RESULTS

Overall inter-observer agreement for the CDD was high, with a kappa value of 0.905 (95% CI = 0.850-0.960) for observers A and B, while the concordance between radiological and surgical findings was weak (kappa values = 0.213 and 0,248, respectively and 95% CI = 0.106 to 0.319 and 95% CI = 0.142 to 0.355, respectively). When overall morbidity, mortality and the need of a terminal colostomy were considered as main endpoints no concordance was observed between surgical and radiological findings and the CDD (P=NS).

CONCLUSIONS

The need for a more accurate classification of ACD, able to better stage this emergency, and to provide surgeons with reliable information for the best treatment is advocated.

Enteroscopy in children

INTRODUCTION

Device-assisted enteroscopy is a new endoscopic technique for the evaluation of small bowel in adults and children. Data in pediatric population are limited. This review aims to identify diagnostic and therapeutic benefits of enteroscopy in children.

METHODS

We have analysed paediatric literature on device-assisted enteroscopy focusing on indications, technical aspects and complications, with attention given to adult publications that may be applicable to the paediatric population.

RESULTS

Obscure gastrointestinal bleeding, Crohn's disease and small bowel polyps are the main indications of enteroscopy in children. Device-assisted enteroscopy has high diagnostic yield for the main paediatric indications, but MR-enterography and capsule endoscopy should be used beforehand in diagnostic work-up to better identify candidates for enteroscopy and to improve its diagnostic and therapeutic yield. Major complications are rare and mostly related to therapeutic procedures.

CONCLUSION

Despite limited data in the paediatric population, device-assisted enteroscopy represents a useful and safe endoscopic technique in children. Its use, combined with MR-enterography and capsule endoscopy, allows identification and treatment of many of the small bowel paediatric diseases with a low risk of complications.

Current tecniques and new perpectives research of magnetic resonance enterography in pediatric Crohn's disease

Crohn's disease affects more than 500000 individuals in the United States, and about 25% of cases are diagnosed during the pediatric period. Imaging of the bowel has undergone dramatic changes in the past two decades. The endoscopy with biopsy is generally considered the diagnostic reference standard, this combination can evaluates only the mucosa, not inflammation or fibrosis in the mucosa. Actually, the only modalities that can visualize submucosal tissues throughout the small bowel are the computed tomography (CT) enterography (CTE) with the magnetic resonance enterography (MRE). CT generally is highly utilized, but there is growing concern over ionizing radiation and cancer risk; it is a very important aspect to keep in consideration in pediatric patients. In contrast to CTE, MRE does not subject patients to ionizing radiation and can be used to detect detailed morphologic information and functional data of bowel disease, to monitor the effects of medical therapy more accurately, to detect residual active disease even in patients showing apparent clinical resolution and to guide treatment more accurately.

Diagnosis of Small-Bowel Diseases: Prospective Comparison of Multi-Detector Row CT Enterography with MR Enterography

PURPOSE

To prospectively compare the accuracies of computed tomographic (CT) enterography and magnetic resonance (MR) enterography for the detection and characterization of small-bowel diseases.

MATERIALS AND METHODS

The institutional review board approved the study protocol, and informed consent was obtained from all participants. From June 2009 to July 2013, 150 consecutive patients (81 men and 69 women; mean age, 38.8 years; range, 18-74 years), who were suspected of having a small-bowel disease on the basis of clinical findings and whose previous upper and lower gastrointestinal endoscopy findings were normal, underwent CT and MR enterography. Two independent readers reviewed CT and MR enterographic images for the presence of small-bowel diseases, for differentiating between inflammatory and noninflammatory diseases, and for extraenteric complications. The histopathologic findings of surgical (n = 23) and endoscopic (n = 32) biopsy specimens were used as the reference standard; the results of video-capsule endoscopy (n = 36) and clinical follow-up (n = 59) were used only to confirm the absence of small-bowel disease.

RESULTS

MR and CT enterography were successfully performed in all 150 patients. Overall sensitivity, specificity, and accuracy, respectively, in identifying patients with small-bowel lesions were 75.9% (41 of 54), 94.8% (91 of 96), and 88.0% (132 of 150) for CT enterography and 92.6% (50 of 54), 99.0% (95 of 96), and 96.7% (145 of 150) for MR enterography. The sensitivity of MR enterography was significantly higher than that of CT enterography for the detection of both overall small-bowel diseases (P = .0159) and neoplastic diseases (P = .0412) but not for the detection of inflammatory diseases (P > .99) or noninflammatory and nonneoplastic diseases (P = .6171).

CONCLUSION

MR enterography is more accurate than CT enterography in the detection of small-bowel diseases; MR enterography was more accurate in detecting neoplastic diseases in particular.

Small bowel imaging of inflammatory bowel disease

The study of the small bowel (SB) has always been challenging both for clinicians and radiologist. It is a long and tortuous tube that can be affected by various pathologies whose signs and symptoms are usually non specific and can mimic other acute abdominal disorders. For these reasons, imaging plays a central role in the diagnosis of the different pathological conditions that can occur. They are important also in the management and follow up of chronic diseases. We expose and evaluate all the radiological methods that are now available for the study of the SB with particular emphasis on the technological improvement of cross-sectional imaging, such as computed tomography (CT) and magnetic resonance imaging (MRI). These techniques have, infact, highly improved in terms of execution times (fast acquisitions images), patients discomfort and radiation dose, for CT, with consequent reduced biological risks. Moreover, the new post-processing options with multiplanar reconstruction and isotropic images have made significant changes in the evaluation of the exams. Especially MRI scans have been improved by the advent of new sequences, such as diffusion weighted imaging and cine-MRI, parallel imaging and breath-hold sequences and can provide excellent soft-tissue contrast without the use of ionizing radiations.

Use of Imaging Techniques in Inflammatory Bowel Diseases That Minimize Radiation Exposure

The use of imaging in the management of inflammatory bowel disease (IBD) has grown exponentially in the last few years. This has raised concerns about the risk of high cumulative level of radiation exposure from medical imaging in IBD patients during their lifetime, especially when the disease begins in pediatric age. Physicians caring for IBD children should be aware of the malignant potential of ionizing radiation and of the availability of alternative radiation-free techniques such as magnetic resonance imaging (MRI) and ultrasonography (US), in order to use them whenever possible. This review will focus on the value of US and MRI in pediatric IBD.

Magnetic resonance enterography, small-intestine contrast US, and capsule endoscopy to evaluate the small bowel in pediatric Crohn's disease: a prospective, blinded, comparison study

BACKGROUND

Small-bowel (SB) disease is a severe clinical entity among the phenotypes of Crohn's disease (CD).

OBJECTIVE

To assess sensitivity, specificity, and accuracy of magnetic resonance enterography (MRE), small-intestine contrast US (SICUS), and capsule endoscopy (CE) in the diagnosis of pediatric SB-CD.

DESIGN

Prospective, blinded, comparison study.

SETTING

Tertiary center for pediatric inflammatory bowel disease.

PATIENTS

Children with known or suspected CD. Diagnosis of SB obstruction at SICUS or MRE excluded patients from the study.

INTERVENTION

Patients underwent ileocolonoscopy, MRE, SICUS, and CE over a 7-day period. For the imaging evaluation, SB was divided into 3 segments: jejunum, proximal and mid ileum, and terminal ileum.

MAIN OUTCOME MEASUREMENTS

The performance of each method was compared to a consensus reference standard for upper SB and to ileocolonoscopy for the terminal ileum.

RESULTS

Twenty-five patients completed the study. In the jejunum, the sensitivity of SICUS and CE was 92%, which was not significantly higher than MRE (75%); the specificity of CE (61%) was significantly lower than that of MRE (P = .04). In the proximal and mid ileum, MRE and CE did not have significantly higher sensitivity (100%) than SICUS (80%), but CE was less specific (P > .05). At the terminal ileum, SICUS and MRE were slightly more sensitive than CE (94% vs. 81%); however, the latter was more specific.

LIMITATIONS

Use of the consensus reference standard for upper SB. Small number of patients.

CONCLUSION

SICUS, MRE, and CE are all effective options for imaging SB. An integrated use of different tools should be suggested to achieve a complete assessment of the SB in children with suspected or confirmed CD.

Stone disease in pregnancy: imaging-guided therapy

Renal colic is the most frequent nonobstetric cause for abdominal pain and subsequent hospitalization during pregnancy. The physio-anatomical changes in the urinary tract and the presence of the fetus may complicate the clinical presentation and management of nephrolithiasis. Ultrasound (US) is the primary radiological investigation of choice. Magnetic resonance urography (MRU) and low-dose computed tomography (CT) have to be considered as a second- and third-line test, respectively. If a study that uses ionizing radiation has to be performed, the radiation dose to the fetus should be as low as possible. The initial management of symptomatic ureteric stones is conservative during pregnancy. Intervention will be necessary in patients who do not respond to conservative measures. Therefore, it is crucial to obtain a prompt and accurate diagnosis to optimize the management of these patients. Teaching Points • In pregnancy, renal colic is the most frequent nonobstetric cause for abdominal pain and hospitalization. • Magnetic resonance urography should be considered when ultrasound is nondiagnostic. • Low-dose CT should be considered as a last-line test during pregnancy.

Capsule endoscopy in pediatrics: A 10-years journey

Video capsule endoscopy (CE) for evaluation the esophagus (ECE), small bowel (SBCE) and the colon (CCE) is particularly useful in pediatrics, because this imaging modality does not require ionizing radiation, deep sedation or general anesthesia. The risk of capsule retention appears to be dependent on indication rather than age and parallels the adult experience by indication, making SBCE a relatively safe procedure with a significant diagnostic yield. The newest indication, assessment of mucosal change, greatly enhances and expands its potential benefit. The diagnostic role of CE extends beyond the SB. The use of ECE also may enhance our knowledge of esophageal disease and assist patient care. Colon CCE is a novel minimally invasive and painless endoscopic technique allowing exploration of the colon without need for sedation, rectal intubation and gas insufflation. The limited data on ECE and CCE in pediatrics does not yet allow the same conclusions regarding efficacy; however, both appear to provide safe methods to assess and monitor mucosal change in their respective areas with little discomfort. Moreover, although experience has been limited, the patency capsule may help lessen the potential of capsule retention; and newly researched protocols for bowel cleaning may further enhance CE’s diagnostic yield. However, further research is needed to optimize the use of the various CE procedures in pediatric populations.

Imaging of the small bowel: Crohn’s disease in paediatric patients

In more than 20% of all patients, the Crohn’s disease presents before the age of 18years. The diagnosis and management of Crohn’s disease in children has changed dramatically over the last decade, mainly due to increased awareness, availability of newer diagnostic modalities such as magnetic resonance imaging (MRI) and newer, more powerful treatments such as biologics. Imaging of the small bowel is needed for diagnosis, management, follow-up and also evaluation of the disease in terms of location, extent, activity and complications. We review all the methods (barium examinations, ultrasonography, computed tomography, MR, and computed tomography- positron emission tomography) commonly used for imaging the small bowel in paediatric patients with Crohn’s disease analyzing the advantages and disadvantages of each modality, with particular emphasis on MR imaging.

Imaging for acute pelvic pain in pregnancy

Acute pelvic pain in pregnancy presents diagnostic and therapeutic challenges. Standard imaging techniques need to be adapted to reduce harm to the foetus from X-rays because of their teratogenic and carcinogenic potential. Ultrasound remains the primary imaging investigation of the pregnant abdomen. Magnetic resonance imaging (MRI) has been shown to be useful in the diagnosis of gynaecological and obstetric problems during pregnancy and in the setting of acute abdomen during pregnancy. MRI overcomes some of the limitations of ultrasound, mainly the size of the gravid uterus. MRI poses theoretical risks to the foetus and care must be taken to minimise these with the avoidance of contrast agents. Teaching Points • Ultrasound and MRI are the preferred investigations for acute pelvic pain during pregnancy. • Ultrasound remains the primary imaging investigation because of availability and portability. • MRI helps differentiate causes of acute pelvic pain when ultrasound is inconclusive.

Penile fracture: penoscrotal approach with degloving of penis after Magnetic Resonance Imaging (MRI)

Fracture of the penis, a relatively uncommon emergency in Urology, consists in the traumatic rupture of the tunica albuginea of the corpus cavernosum. Examination and clinical history can be highly suspicious of penile fracture in the majority of cases and ultrasonography (USS) can be useful to identify the exact location of the tunical rupture, which is proximal in 2/3 of cases and therefore manageable through a penoscrotal approach. Although expensive and not readily available in the acute setting, Magnetic Resonance Imaging (MRI) may play a role in the differential diagnosis with rupture of a circumflex or dorsal vein of the penis or when the tunical rupture is not associated with tear of the overlying Buck's fascia. This form of imaging is more sensitive than USS at identifying the presence of a tunical tear. The treatment of choice is immediate surgical repair, which allows preserving erectile function and minimizing corporeal fibrosis.

Spontaneous intramural hematoma of rectum in a patient on anticoagulant therapy: case report and review of literature

AIM

Gastrointestinal spontaneous hematomas (GSHs) represent 5-10% of patients with acute abdomen. Conservative treatment is the most common approach but the bowel perforation can be a fatal complication. In patients with spontaneous rectal wall hematoma, high comorbidity and abdominal signs of acute abdomen but without radiological signs of intestinal perforation, an early exploratory laparotomy should be considered.

CASE PRESENTATION

A 70-year-old man with severe dilatative cardiomyopathy and chronic obstructive pulmonary disease (COPD) on anticoagulant therapy was admitted with acute abdominal pain and anemia. An abdominal CT scan showed a perihepatic, perisplenic and parietocolic effusion associated with a retro-rectal hematoma measuring 6 × 6 × 14 cm without signs of active bleeding. Because of sudden onset of signs of peritonitis, a laparotomy was performed which showed an ischemic perforation of the sigmoid-rectal junction. We performed a recto-sigmoid resection (Hartmann operation) but the patient died twelve days later for septic shock.

DISCUSSION

In patients with GSH the main problem is represented by the choice between conservative and surgical treatment. In case of complications, such as active and persistent intra-abdominal bleeding, wall ischemia with or without bowel perforation and peritonitis, surgical treatment is mandatory. The absence of radiological signs of perforation can cause a delay of surgical treatment with unfavourable outcome especially in patient with rectal hematoma and severe comorbidity.

CONCLUSIONS

GSHs of rectum are uncommon but a strict clinical monitoring is crucial because the extraperitoneal position make it possible a late clinical or radiological identification of perforation and a late laparotomy.

Acute pancreatitis complicated by infected pseudocyst in a child with pancreas divisum

INTRODUCTION

Acute pancreatitis occurs less frequently in children than in adults, although it seems to be more common than has been considered in the past. There are several causes of pancreatitis in childhood: trauma, infections or structural gland anomalies as pancreas divisum.

CASE PRESENTATION

We report a case of non-traumatic severe acute pancreatitis in a 8-year-old girl with pancreas divisum, complicated by a rapid formation of a large infected pseudocyst which required a surgical internal drainage by a Roux-en-Y cystojejunostomy.

DISCUSSION

Pancreas divisum is the most common congenital anomaly of the pancreas with an incidence of 3-10% of population, and its role in causing acute or recurrent pancreatitis is still controversial. There are only sporadic observations of acute pancreatitis complicated by pseudocyst in children with pancreatic anomalies and its treatment is not standardized. Three different approaches have been described to treat a pancreatic pseudocyst: percutaneous, endoscopic or surgical drainage. We decided to perform a pseudocyst-jejunostomy because of the disease severity.

CONCLUSION

Even in the non-invasive era, the surgical approach to treat a large complicated pseudocysts in children still represents a safe and feasible approach in emergencies as acute abdomen, bleeding or sepsis. Complications of percutaneous and endoscopic drainages are avoided and long term results are excellent.

KEY WORDS

Acute pancreatitis, Pancreas divisum, Pancreatic pseudocyst.

Disease course and efficacy of medical therapy in stricturing paediatric Crohn's disease

BACKGROUND

Stricturing is the most common complicated phenotype in paediatric Crohn's disease, but only few studies have described its course, while data on the outcome of medical treatment are scanty.

AIM

To retrospectively describes the course of paediatric stricturing Crohn's disease and assess clinical and imaging response to medical therapy.

PATIENTS AND METHODS

Thirty-six patients with stricturing Crohn's disease were identified by our department database. Paediatric Crohn's disease activity index, need of surgery and magnetic resonance were evaluated as outcomes at 6, 12, 18 and 24 months after detection of stenosis.

RESULTS

Strictures were ileal, ileocolonic and colonic in 61%, 28% and 11% of patients. Thirteen (36%) had stricturing disease at the diagnosis of Crohn's disease, while 64% developed it at the follow-up. At baseline, 89% had medical treatment, while 11% surgery. At 6, 12, 18, and 24 months, 53%, 50%, 42%, and 35% had complete response to medical treatment, respectively. Overall, 44% were unresponsive to medical therapy and required surgery at the follow-up. Responders and non-responders significantly differed for inflammatory imaging findings at the stenosis detection.

CONCLUSIONS

A stricturing phenotype is not uncommon at the diagnosis of Crohn's disease in children. Medical therapy seems poorly effective in avoiding intestinal resection. Magnetic resonance imaging is valuable in identifying patients who will benefit from medical therapy.

Mirizzi Syndrome in a patient with an accessory hepatic duct

Mirizzi syndrome (MS) represents an uncommon clinical condition, being characterized by a narrowing of the common hepatic duct or its erosion by stones impacted in the cystic duct or gallbladder Hartman's pouch. Very uncommonly, MS can be reported in patients with contemporaneous bile duct anomalies. The case is reported of a 76-year-old Caucasian woman with a MS with a cholecystobiliary fistula and a contemporaneous aberrant biliary duct for the right posterior segments.Due to the presence of an anatomical abnormality, an open approach was decided: also during surgery, it was impossible to clarify which part of the biliary tree the accessory duct merged into. After surgery, post-operative course was uneventful: the patient is alive without medical problems (follow-up: 16 months). MS represents a challenge for the surgeon. Contemporaneous presence of biliary abnormalities is anecdotic, increasing the risk of iatrogenic injuries. An open approach may be preferred in these conditions.

Enteroscopy in paediatric Crohn's disease

Small bowel evaluation is crucial in children with suspected inflammatory bowel disease to differentiate Crohn's disease from other enteropathies, in making therapeutic decisions and planning the follow-up. Endoscopic investigation of small bowel has historically been difficult due to the length and tortuosity of the organ itself. New technology, introduced over the past decade, allows minimally invasive and detailed endoscopic evaluation of the entire small bowel mucosa. While understudied in the paediatric population, literature is emerging supporting the use of these techniques in children. In this review we will provide an overview on the currently available technology, on its feasibility in paediatric age and on the available literature concerning the use of enteroscopy in paediatric Crohn's disease.

Multi-modal imaging technologies in cardiovascular risk assessment

Atherosclerotic plaques can be responsible for life-threatening cardiovascular and cerebrovascular events. Some features of the plaque, such as a thin fibrous cap, large necrotic core, macrophage infiltration, neovascularization, and intraplaque hemorrhage, are associated with a major risk of such events and so their assessment is fundamental. Novel imaging techniques, each one with its own strength and drawbacks, can help in the evaluation and quantification of atherosclerosis. An analysis of the recent literature was carried out. The different techniques were compared by evaluating the accuracy of each one in the detection and assessment of the atherosclerotic plaque's features named above.

Magnetic resonance imaging of small bowel neoplasms

Magnetic resonance (MR) imaging is rapidly increasing clinical acceptance to evaluate the small bowel and can be the initial imaging method to investigate small bowel diseases. MR examinations may provide the first opportunity to detect and characterize tumours of the small bowel. Intra- and extraluminal MR findings, combined with contrast enhancement and functional information, help to make an accurate diagnosis and consequently characterize small bowel neoplasms. MR enteroclysis should be recommended for the initial investigation in patients suspected of having small bowel tumours. In this article, the MR findings of primary small bowel neoplasms are described and the MR findings for the differential diagnosis are discussed.

Effectiveness of clinical guidelines in the management of acute sigmoid diverticulitis. Results of a prospective diagnostic and therapeutic clinical trial

BACKGROUND

Evidence-based criteria in the therapeutic choice for sigmoid acute diverticulitis (AD) are lacking. It is necessary to differentiate an acute episode of diverticular disease, not complicated (NCAD) and complicated (CAD) because these stages of diverticular disease needs different approach.

METHODS

In a prospective study on 377 consecutive patients admitted for AD, 265 had NCAD and 112 CAD diagnosed with CT scan. Thirty-six of 265 with NCAD were operated on due to two or more previous episodes of AD. On 188 patients with NCAD followed-up, 35 had further episodes of NCAD and 2 had CAD. On 112 CAD patients, 61 had Hinchey I and were submitted to colonic resection. Twenty-three of 24 patients with Hinchey II were treated with percutaneous drainage. All Hinchey II patients were operated on. All the 13 patients with Hinchey III and IV had emergency surgery.

RESULTS

We had no mortality and respectively 9.8% and 30% morbidity in Hinchey I and II patients. In Hinchey II patients percutaneous drainage was successful in 21 on 23 (91.3%). In 13 Hinchey III and IV patients the mortality rate was 25%. The comparison of CT findings and pathological results showed a sensitivity of 100% and predictive positive value of respectively 94.4, 96.7, 100 and 100% for NCAD, Hinchey I, Hinchey II and Hinchey III-IV.

CONCLUSIONS

The therapeutic approach of diverticular disease needs to differentiate among an acute episode, NCAD and CAD. Evidence-based therapeutic choices can be reached only by homogeneous diagnostic criteria obtained by CT scan.

Investigation of small bowel in pediatric Crohn's disease

Investigation of the small bowel has been traditionally a challenge for pediatric gastroenterologists due to its location, anatomical tortuosity, and invasiveness of the available techniques. Recently, there has been a remarkable improvement in imaging and endoscopic tools aimed at exploring successfully the small intestine in inflammatory bowel disease. The former are represented by ultrasonography (either alone or with administration of oral contrast agents) and by magnetic resonance: both have provided accurate methods to detect structural bowel changes, diminishing patient discomfort and precluding radiation hazard. The use of traditional radiologic techniques such as fluoroscopy have been markedly reduced due to radiation exposure and inability to depict transmural inflammation or extraluminal complications. Among the novel endoscopic tools, capsule endoscopy and balloon-assisted enteroscopy have tremendously opened new diagnostic and therapeutic perspectives, by allowing the direct visualization of small intestinal mucosa and, through enteroscopy, histological diagnosis as well as therapeutic interventions such as stricture dilation and bleeding treatment. These endoscopic techniques should always be preceded by imaging of the intestine in order to identify strictures. This review describes the most recent progress with the employment of novel imaging and endoscopic methodologies for investigating the small bowel in children with suspected or established Crohn's disease.

Spontaneous renal artery dissection diagnosed by unenhanced magnetic resonance angiography: case report

A 47-year-old patient is presented who was admitted to the emergency department with complaints of right-sided flank pain and hypertension. His creatinine and glomerular filtration rate were 2.5 mg/dl and 37 ml/min respectively, so that contrast media administration was contraindicated. The unenhanced magnetic resonance angiography image obtained with 3D in-flow inversion recovery sequence showed right renal artery dissection, without aortic dissection. Selective renal angiography confirmed the diagnosis and a stent was placed in the renal artery. The patient was free of pain after stenting, with normalized laboratory values and blood pressure.

MRI of the small-bowel: how to differentiate primary neoplasms and mimickers

MRI of the gastrointestinal tract is gaining clinical acceptance and is increasingly used to evaluate patients with suspected small-bowel diseases. MRI may be performed with enterography or enteroclysis, both of which combine the advantages of cross-sectional imaging with those of conventional enteroclysis. In this paper, MRI features of primary small-bowel neoplasms, the most important signs for differential diagnosis and the diseases that can be considered as mimickers of small-bowel neoplasms, are discussed.

Usefulness of single-balloon enteroscopy in pediatric Crohn's disease

BACKGROUND

Single-balloon enteroscopy (SBE) has not been reported in pediatric Crohn's disease (CD).

OBJECTIVE

To determine technical performance, yield, safety, and clinical impact of SBE in pediatric patients with suspected and established CD.

DESIGN

Prospective, cohort study.

SETTING

Academic tertiary-care referral center.

PATIENTS

This study involved 16 patients (group A) with suspected CD and unspecific upper and lower GI endoscopy results and 14 patients (group B) with longstanding CD with previous surgery and showing signs unaccountable by conventional endoscopy. All underwent magnetic resonance imaging, and 14 patients in group A also underwent wireless capsule endoscopy.

INTERVENTION

SBE.

MAIN OUTCOME MEASUREMENTS

SBE diagnostic and therapeutic yield, technical performance, clinical impact, and safety.

RESULTS

In group A, SBE aided diagnosis of CD in 12 patients and eosinophilic enteropathy in 2 patients, whereas no lesions were found in 2 patients. WCE was diagnostic of CD in 3 patients, suggestive of CD in 7 patients, and unspecific in the remaining patients. In group B, SBE revealed moderate-to-severe disease activity in most patients, leading to the introduction of or change in biological therapy, with a marked decrease in the pediatric Crohn's disease activity index scores. SBE allowed successful dilation of small-bowel strictures in 2 patients in group A and 3 in group B. No complications occurred.

LIMITATIONS

Small sample size, no direct comparison with imaging or other endoscopic techniques.

CONCLUSION

SBE is a useful and safe endoscopic procedure for evaluating the small bowel in pediatric patients with suspected or established CD. Not only does it allow a definite diagnosis of CD when the latter is uncertain, but it is also very effective in the management of small-bowel strictures, thus avoiding surgery. It may be helpful in redirecting therapy in selected CD patients.

Ascaris Lumbricoides infestation and intestinal MZBCL: a surgical and radiological perspective

Ascaris Lumbricoides is the most common worm found in human beings and it is the largest of the intestinal nematodes parasitizing humanity. The most common complication of Ascariasis is mechanical bowel obstruction caused by a large number of worms. Bowel obstruction can also be caused by various toxins released by the worms. A large worm bolus can also cause volvulus or intussusception. We report a case of Intestinal Obstruction due to an Ileal MZBCL in an Ascaris. Lumbricoides infestation setting.

[MRI of extraperitoneal rectal carcinoma]

Last years technological developments in imaging field have made a substantial contribution to diagnosis and staging of rectal cancer. Endorectal ultrasound and MRI with endorectal coil are very useful in rectal cancer initial staging thanks to their ability to distinguish between the rectal wall layers. Major ultrasound limitations are presence of inflammations, desmoplastic reaction and small field of view which limits evaluation of perirectal invasion. MRI with phased-array coils, instead, allows depiction of mesorectum and to assess the distance between tumor and mesorectal fascia. Unfortunately CT shows low accuracy compared to MRI in local staging because it fails to distinguish the rectal wall layers. The criterion used in assessing nodal involvement remains unfortunately still the dimensional one even if new contrast media based on nano-iron particles look promising in this regard On reassessment after chemo-radiotherapy treatment, MRI proved to be a very accurate tool thanks to its ability to detect tumor downstaging, disappearance of mesorectal fascia infiltration or even to show a complete response. The presence of recurrence can be studied by contrast enhanced perfusion-MRI or with good accuracy using PET which, however, presents major technical limitations at present.

[Role of imaging in the evaluation and characterization of adrenal masses]

The primary role of imaging in identification as well as in characterization adrenal lesions has been demonstrated by several studies. The recent technologic progress has allowed to identify adrenal lesions even when they are very small, with a consequent conspicuous increase of the frequency of incidentalomas. Computed Tomography, Magnetic Resonance and Nuclear Medicine are routinely used to evaluate adrenal glands and their pathologic conditions. The aim of this article is to show how the imaging is employed to assess adrenal masses, with special regard to the contribution given by Computed Tomography (CT) and Magnetic Resonance (MR) imaging to the differential diagnosis between benignant and malignant lesions.

Prospective study comparing multi-detector row CT and endoscopy in acute gastrointestinal bleeding

BACKGROUND

Upper and lower acute gastrointestinal bleeding (AGIB) is associated with high rates of mortality and morbidity. The latest computerized tomography (CT) imaging techniques play an important role in the treatment of this pathology.

METHODS

Twenty-nine patients with severe AGIB (11 upper, 18 lower), all hemodynamically stable, underwent endoscopy followed by a multi-detector row CT (MDCT) scan. Endoscopic and MDCT accuracy for the anatomical localization and etiology of AGIB was assessed, the diagnosis being considered correct when the two procedures were concordant or when the diagnosis was confirmed by angiographic, surgical, or post-mortem findings.

RESULTS

The sensitivity in identifying the site and etiology of bleeding was, respectively, 100% and 90.9% for the MDCT scan, compared with 72.7% and 54.5% for endoscopy in upper AGIB, and 100% and 88.2% for the MDCT scan, compared with 52.9% and 52.9% for endoscopy, in lower AGIB.

CONCLUSIONS

Considering the advantages of MDCT over endoscopy, we propose a new diagnostic algorithm for AGIB.

Small-bowel neoplasms: prospective evaluation of MR enteroclysis

PURPOSE

To prospectively evaluate the accuracy of magnetic resonance (MR) enteroclysis in the detection of small-bowel neoplasms in symptomatic patients, with conventional endoscopy, tissue specimen, capsule endoscopy, conventional enteroclysis, and follow-up findings as reference standards.

MATERIALS AND METHODS

The study protocol was approved by the human research committee, and all patients gave written informed consent. One hundred fifty patients (83 male, 67 female; mean age, 42.6 years; age range, 17-84 years) who were clinically suspected of having small-bowel neoplasm and whose previous upper and lower gastrointestinal endoscopy findings were normal underwent MR enteroclysis. The MR enteroclysis findings were prospectively evaluated for the presence of focal bowel wall thickening, small-bowel masses, and small-bowel stenosis. Positive MR enteroclysis findings were compared with histopathologic examination results obtained after surgical (n = 19) or endoscopic (n = 2) procedures. Negative MR enteroclysis results were compared with the results of enteroscopy (n = 5), capsule endoscopy (n = 53), or conventional enteroclysis with subsequent clinical follow-up (n = 71). The diagnostic performance of MR enteroclysis was analyzed on a per-patient basis.

RESULTS

MR enteroclysis was successfully completed in all 150 patients and enabled correct detection of 19 small-bowel neoplasms, which were confirmed at histopathologic examination: three carcinoid neoplasms, two adenocarcinomas, two stromal tumors, five lymphomas, one angiomatous mass, three small-bowel metastases, one leiomyoma, one adenoma, and one lipoma. Overall sensitivity, specificity, and accuracy in identifying patients with small-bowel lesions were 86% (19 of 22), 98% (126 of 128), and 97% (145 of 150), respectively. Two MR enteroclysis examinations yielded false-positive findings, and three yielded false-negative findings.

CONCLUSION

MR enteroclysis is an accurate modality for detecting small-bowel neoplasms in symptomatic patients.

Dynamic MR imaging of the pelvic floor: a pictorial review

Pelvic floor dysfunctions involving some or all pelvic viscera are complex conditions that occur frequently and primarily affect adult women. Because abnormalities of the three pelvic compartments are frequently associated, a complete survey of the entire pelvis is necessary for optimal patient management, especially before surgical correction is attempted. With the increasing use of magnetic resonance (MR) imaging in assessing functional disorders of the pelvic floor, familiarity with normal imaging findings and features of pathologic conditions are important for radiologists. Dynamic MR imaging of the pelvic floor is an excellent tool for assessing functional disorders of the pelvic floor such as pelvic organ prolapse, outlet obstruction, and incontinence. Findings reported at dynamic MR imaging of the pelvic floor are valuable for selecting patients who are candidates for surgical treatment and for choosing the appropriate surgical approach. This pictorial essay reviews MR imaging findings of pelvic organ prolapse, fecal incontinence, and obstructed defecation. Supplemental material available at http://radiographics.rsnajnls.org/cgi/content/full/e35v1/DC1.

Retrorectal Tumors: The Choice of Surgical Approach Based on a New Classification

Because retrorectal-presacral tumors differ in histologic origin, symptoms, and prognosis, and often involve various neighboring structures, successful treatment of this heterogeneous group of tumors depends on the surgical approach chosen and the specialist surgeons involved. We investigated whether a new classification of retrorectal tumors based on findings from CT and MRI would simplify presurgical planning. The clinical records of a series of 34 patients who underwent surgery for retrorectal tumors from 1989 to 2003 were reviewed. Two radiologists, who were blind to the patients’ records, separately reviewed the preoperative CT and MRI findings and classified tumors according to whether they arose from the presacral area (Group 1), sacrum or spinal cord growing anteriorly (Group 2), or rectum growing posteriorly (Group 3). The preoperative CT and MRI findings for the retrorectal tumors yielded the information required to allow surgery to be properly planned (surgical approach and need to involve various specialist surgeons) in nearly all cases: 17 of the 18 patients (94.5%) with tumors arising from the retrorectal space, all 12 of those with tumors arising from the sacrum or spinal cord, and all four of those with rectal tumors. With the findings yielded by currently available CT and MRI techniques, retrorectal tumors can be anatomically and topographically classified preoperatively so as to allow surgery to be adequately planned in advance and thus optimize the surgical resection.

Retrorectal tumors: the choice of surgical approach based on a new classification

Because retrorectal-presacral tumors differ in histologic origin, symptoms, and prognosis, and often involve various neighboring structures, successful treatment of this heterogeneous group of tumors depends on the surgical approach chosen and the specialist surgeons involved. We investigated whether a new classification of retrorectal tumors based on findings from CT and MRI would simplify presurgical planning. The clinical records of a series of 34 patients who underwent surgeryfor retrorectal tumors from 1989 to 2003 were reviewed. Two radiologists, who were blind to the patients' records, separately reviewed the preoperative CT and MRI findings and classified tumors according to whether they arose from the presacral area (Group 1), sacrum or spinal cord growing anteriorly (Group 2), or rectum growing posteriorly (Group 3). The preoperative CT and MRI findings for the retrorectal tumors yielded the information required to allow surgery to be properly planned (surgical approach and need to involve various specialist surgeons) in nearly all cases: 17 of the 18 patients (94.5%) with tumors arising from the retrorectal space, all 12 of those with tumors arising from the sacrum or spinal cord, and all four of those with rectal tumors. With the findings yielded by currently available CT and MRI techniques, retrorectal tumors can be anatomically and topographically classified preoperatively so as to allow surgery to be adequately planned in advance and thus optimize the surgical resection.

Imaging assessment of acute pancreatitis: a review

Acute pancreatitis is one of the more commonly encountered etiologies in the emergency setting. While in the majority of cases it is a self-limiting disease which responds rapidly to conservative management, in some cases acute pancreatitis may present with a more pronounced, sometimes dramatic, clinical picture and requires immediate medical care to avoid fatal complication. In this context, imaging plays a significant role because it enables identification of the development of the disease and local/systemic complications. The purpose of this article is to offer an overview of the disease and a spectrum of imaging findings in patients with acute pancreatitis, emphasizing the role of ultrasound, computed tomography, and magnetic resonance imaging according to the appropriate clinical context and advantages and limitations of each imaging modality are examined.

[Imaging in diagnosis of acute pancreatitis and its complications]

Pancreatitis is a flogistic disease, caused by activation and digestion of pancreas by its enzymes. Diagnosis is based on integrated evaluation of clinical and laboratoristic data and morphological imaging. To evaluate the severity of pancreatitis there is a clinical classification in interstitial--mild pancreatitis and severe--necrotic one. The evaluation of severity is basic, because it is strictly correlated to the prognosis of the patient. CT has revealed the best method for diagnosis, staging and for evaluate the complications and follow-up and in some cases it is useful for therapeutic change.The abdomen X-Ray in orthostatism is performed in every situation suspected for acute abdominal disease, also if aspecific; the ultrasound can be used as first instance method in patient with clinical suspect of acute pancreatitis; the MR has actually a secondary role for the diagnosis, with only except for dubious cases to exclude primitive tumor of pancreas and pancreatic shock, but it represents, instead, first instance method in patients with adverse reaction to contrast medium. The CPRE has, like angiography, a selective indication.