Perigastric appendagitis: CT and clinical features in eight patients

AIM

To describe perigastric appendagitis (PA) on CT as a new and distinct clinical entity to enable recognition and prevent additional unnecessary investigation or intervention.

MATERIALS AND METHODS

Institutional review board approval was obtained and informed consent was waived. Retrospective review of the clinical data and CT findings in eight patients with PA encountered over 10 years at one institution was performed. The English literature was reviewed and summarized. Two experienced abdominal radiologists reviewed the CT images by consensus.

RESULTS

Seven of eight patients had moderate to severe epigastric pain for 1–7 days. All eight patients (four men, four women; mean age 44 years, range 33–81 years) had no fever or leukocytosis. All underwent abdominal CT which showed ovoid fat inflammation along the course of the perigastric ligaments (gastrohepatic, gastrosplenic, and falciform). Two had gastric wall thickening. Although the inflammation was correctly described, the specific diagnosis was not made on initial interpretation in five patients. Subsequently, they underwent further diagnostic testing [an upper gastrointestinal examination and hepatobiliary iminodiacetic acid (HIDA) cholescintigraphy, an upper endoscopy and MRI examination, HIDA cholescintigraphy, another CT, and an MRI examination, respectively]. The HIDA cholescintigraphy, upper GI examination, and upper endoscopy examinations were normal. No repeated examination was performed on the other three patients. Pain resolved spontaneously in all within two days.

CONCLUSION

Perigastric appendagitis can present with an acute abdomen, which is safely managed conservatively if diagnosed correctly. Radiologists should be aware of the entity to avoid unnecessary intervention, and recognize the CT findings of ovoid fat inflammation in the distribution of the perigastric ligaments.

Capsule endoscopy findings in celiac disease associated enteropathy-type intestinal T-cell lymphoma

Capsule endoscopy is a new technology developed to investigate diseases of the small intestine. It has been shown to be superior to current modalities such as small-bowel radiography and enteroscopy. We describe a patient with long-standing celiac disease who presented with abdominal pain, diarrhea, and weight loss, after many years on a gluten-free diet. The symptom complex and results from small-bowel radiography and computerized tomography raised concern about progression to lymphoma, and ultimately a laparoscopy and small-bowel resection were done for diagnosis. A capsule endoscopy was performed to assess the extent of the patient's enteropathy-type intestinal T-cell lymphoma after three cycles of chemotherapy. We report the first use of capsule endoscopy in the setting of celiac disease associated enteropathy-type intestinal T-cell lymphoma. These endoscopic findings are correlated with those from gross and microscopic pathology and barium small-bowel radiography.

Imaging features of enterohemorrhagic Escherichia coli colitis

OBJECTIVE

The purpose of this article is to define and illustrate the radiologic findings in patients with enterohemorrhagic Escherichia coli colitis.

CONCLUSION

Although not definitive, imaging studies in conjunction with an appropriate clinical history can aid in the early diagnosis of E. coli colitis and exclude surgical conditions. CT is more sensitive than conventional radiography for detection. Contiguous involvement, including the transverse colon, was seen in all patients. Because CT is becoming routine in the initial workup of patients with acute abdominal pain, it is important for the radiologist to suggest E. coli colitis in the proper setting.

Angioedema of the small bowel due to an angiotensin-converting enzyme inhibitor

We describe a case of a 72-year-old woman who presented with two episodes of abdominal pain, vomiting, and diarrhea. Abdominal computed tomographic scans done during each episode demonstrated edema of the small bowel. Review of the patient's history revealed that she had been started on a treatment of lisinopril for hypertension 1 month before the first episode and had her prescribed dose increased 24 hours before each presentation. Angiotensin-converting enzyme (ACE) inhibitor-associated angioedema was suspected and the medication was discontinued. The patient has remained symptom-free while not taking the ACE inhibitor for 1 year. Review of the literature reveals only nine similar cases. All cases, including ours, occurred in women. Angioedema of the small bowel associated with ACE inhibitors is rare and often is not recognized before surgical exploration. Angioedema of the gastrointestinal tract should be considered in symptomatic patients taking ACE inhibitors.

Screening for colorectal cancer

Colorectal cancer is the third most commonly diagnosed cancer and the second leading cause of cancer deaths in the United States. Fortunately, both the incidence and mortality associated with the disease have declined during the past 2 decades. This is likely due, at least in part, to improved efforts at screening and more aggressive removal of adenomatous polyps. However, colorectal cancer screening is still generally underutilized. This article reviews the current status and future outlook for colorectal cancer screening, including a discussion of risk factors for the disease, its anatomic distribution, proposed mechanisms of development from adenomatous polyps, rationale for screening, and screening options. Published literature concerning the cost-effectiveness of colorectal cancer screening is also summarized. The article concludes with a discussion of the emerging consensus regarding the importance of and approaches to screening.

Radiology of ileal pouch-anal anastomosis: normal findings, examination pitfalls, and complications

Ileal pouch-anal anastomosis (IPAA) is a procedure in which an ileal reservoir is constructed after total colectomy and anastomosed to the anus. IPAA is a well-established option for patients who require surgery for chronic ulcerative colitis or familial adenomatous polyposis. Although excellent functional results can be achieved with IPAA, the procedure is associated with an appreciable number of complications, including small bowel obstruction, pouch fistula, anastomotic separation, anastomotic leakage, pelvic infection and abscess, stricture, and pouchitis. However, most of these complications do not require surgical intervention and can be managed with aggressive medical treatment and delay of ileostomy closure. Radiography of the IPAA pouch is routinely performed before closure of the diverting ileostomy to evaluate the integrity of the pouch and anastomosis. Such radiography can demonstrate many of the complications of IPAA, thus allowing identification of patients who may require intervention or delay before closure of the ileostomy.

AIDS-related cholangiopancreatographic changes

The cholangiographic and pancreatographic appearances of the acquired immunodeficiency syndrome (AIDS) associated cholangitis were evaluated in 26 patients. Twenty-four patients were diagnosed by retrograde cholangiography or endoscopic cholangiopancreatography (ERC or ERCP). One patient was diagnosed by T-tube cholangiography and another patient by transhepatic cholangiography. The radiographic findings ranged from intrahepatic ductal abnormalities with or without involvement of the extrahepatic biliary tree (eight patients) to irregularities and strictures involving the ampulla of Vater or the intrapancreatic portion of the common bile duct (CBD) with proximal dilatation (18 patients). Significant strictures involving the juxta-ampullary pancreatic duct were identified in six of 12 patients. Twenty-one of the 26 patients had associated infections which included: Cryptosporidium (CS), Mycobacterium avium intracellulare (MAI), cytomegalovirus (CMV), Microsporidium (MSP), and Isospora (ISP). Three patients were operated upon for acute acalculous cholecystitis. In each instance, organisms were identified in both the bile duct and the inflamed gallbladder.

Ischemic bowel disease

The pathophysiologic events occurring in the ischemic process are described so that radiologic findings are understood rather than memorized. Depending on the underlying disease, the ischemic process can lead almost instantly to infarction or may be so indolent that years or even decades of low-grade ischemia may occur. The spectrum is discussed and illustrated.

Midgut volvulus in an elderly patient

In adults, congenital anomalies of intestinal rotation are usually incidental findings. Any symptoms present may be the result of intermittent volvulus of the small bowel. We report classic fluoroscopic, computed tomographic, and angiographic findings in what is believed to be the oldest reported patient with this entity.

Acute pyelonephritis after transrectal ultrasonographically guided biopsy of the prostate: diagnosis by computed tomography

Acute pyelonephritis developed in a 67-yr-old man after transrectal ultrasonographically guided biopsy of the prostate. The clinical presentation and results of excretory urography were nondiagnostic. Diagnosis was made by computed tomography, which was delayed 12 h after i.v. administration of contrast medium.

Hepatobiliary anomalies associated with polysplenia syndrome

The report of a 29-year-old woman with polysplenia syndrome, Crohn's disease, and bilateral cataracts is presented. The patient was noted to have a right-sided stomach and small bowel, Crohn's ileitis, and a left-sided colon. Results of roentgenography of the chest and echocardiography were consistent with a diagnosis of hypoplasia of the inferior vena cava with azygos continuation. The patient underwent laparotomy with cholecystectomy, exploration of the common bile duct, and choledochoscopy for cholelithiasis, choledocholithiasis, and chronic cholecystitis. Laparotomy revealed a liver that had two lobes, each with the morphologic appearance of the left lobe. The gallbladder was centrally located. T-tube cholangiography revealed a quadruplication of the intrahepatic biliary ducts. To our knowledge, this patient is the only known adult with this syndrome in whom cholangiography demonstrated isomerism of the biliary tree. A review of the literature on this subject is given with emphasis on biliary anomalies.

Surgical aspects of sclerosing cholangitis. Results in 178 patients

Of 178 patients with sclerosing cholangitis treated since 1950, 88 patients had associated inflammatory bowel disease, 72 had no such history, and 18 had iatrogenic injury or stone disease. A total of 233 biliary operations were performed, with a 75% rate of temporary improvement after initial operation. Subsequent operations resulted in a lower success rate and a higher mortality rate. Radiologic findings included predominant extrahepatic, intrahepatic, and diffuse disease in 29%, 28%, and 43% of patients, respectively; no survival differences were noted. Seventy-five of one hundred three deaths (73%) were related to liver failure, bleeding, or sepsis. Of 14 patients undergoing portosystemic shunt, 13 died of surgical complications or related disease. Orthotopic liver transplantation was performed in 16 patients and resulted in eight deaths, mainly in patients who had previously undergone extensive surgical treatment. No survival differences were seen between the patients with inflammatory bowel disease, those without the condition, or those who had colectomy. Surgical treatment in patients with sclerosing cholangitis should be minimized. Orthotopic liver transplantation should be offered as the treatment of choice for patients with portal hypertension, refractory cholangitis, advanced cirrhosis, or progressive liver failure.

Gastrosplenic fistula: complication of adenocarcinoma of stomach

Penetration of the spleen by an adenocarcinoma of the stomach is described in a patient undergoing chemotherapy. The diagnosis was made by computed tomography.

Manual compression device for fluoroscopy

A device for manual compression and palpation during supine fluoroscopy has been designed. It enables effective use of the physiologic grasping and lever force potentials of the hand and wrist. The device permits optimal fluoroscopic palpation and compression techniques and prevents direct exposure to the lead-gloved hand.

Computed tomographic findings of giant intestinal pseudopolyposis

The cases of 3 patients with giant intestinal pseudopolyposis are presented. Giant pseudopolyposis complicated chronic ulcerative colitis in 2 patients and granulomatous colitis in 1 patient. Each patient was evaluated with either barium or Gastrografin enema as well as with computed tomography (CT) after administration of oral contrast material. The unique manifestations of this unusual lesion as demonstrated by computed tomography are described.

Algorithm for the detection of fine clustered calcifications on film mammograms

An algorithmic process for the detection and marking of clustered calcifications in digitized film-screen mammograms has been applied to mammograms from 50 clinical cases sampled at two digitization levels, in both the craniocaudal and mediolateral views. In all but one case the detector accurately located suggestive clusters found by radiologists in normal screening. In five cases additional clusters were also found by the detector. The detector has a negligible false-positive rate for the detection of clustered calcifications, although it is sensitive to clusters of emulsion defects displayed as artifactual calcification densities in the original film. The detector is flexible in structure and is easily adapted to various calcification/cluster criteria. The detector shows considerable promise when applied to clinical examples but will require refinement before formal testing.

Breast calcifications: analysis of imaging properties

The imaging characteristics of microcalcifications in both benign and malignant breast conditions were analyzed in 48 digitized film mammograms. Each case included in this analysis had findings considered suggestive of malignancy by the radiologist, with the underlying histologic structure determined by excisional biopsy. Imaging properties of each microcalcification--such as pixel intensity, relative location, distribution, size, and local neighborhood intensities--were recorded. This information was statistically analyzed at the population level according to such selection criteria as histologic type, size of calcification, and cluster size. Distribution ranges were determined for these criteria. Statistical differences between data from benign and malignant cases show the average distance between calcifications in malignant conditions was greater than in benign conditions, and tissue region averages surrounding calcifications associated with malignant conditions were consistently higher than those for benign conditions.

Computed tomographic evaluation of spigelian hernia

Spigelian hernia is an uncommon hernia of the anterior abdominal wall. Because of its insidious nature and at times nonspecific physical findings associated with it, the diagnosis of this hernia is often not made. Typically, the hernial orifice is small, and strangulation of the contents of the hernial sac can occur. Computed tomography permits the distinction between spigelian hernia and other anterior abdominal wall or intra-abdominal masses. When a spigelian hernia is found, CT is useful in establishing contents of the hernial sac and defects in the fascial plane.

Computed tomography of xanthogranulomatous cholecystitis

A case is presented of xanthogranulomatous cholecystitis that resembled carcinoma of the gallbladder on computed tomography. The large, infiltrating mass satisfied the criteria for massive carcinoma of the gallbladder.

Digital subtraction angiography

Digital subtraction angiography is a new imaging technique that uses a computer to subtract background distractions and to enhance contrast and density. The intravenous administration of contrast material permits safe outpatient screening for arterial disease. The exact role of intravenous digital subtraction angiography in cerebrovascular disease is still in evolution and remains the subject of debate. The value of intravenous digital subtraction angiography in screening for renovascular hypertension is less controversial, but selection of patients remains a subject for further study. Intra-arterial digital subtraction angiography has become a standard imaging technique that offers both the inherent safety produced by reduction of the volume of contrast material and the added safety afforded by reduction of both the size of the catheter and the time required to perform complex arterial interventional procedures. With the evolution of more sophisticated computed technology and radiographic equipment, the impact of both intravenous and arterial digital subtraction angiography will become even more dramatic.

Intraluminal mass of the left pulmonary artery

Intravenous digital subtraction angiography demonstrated a polypoid carcinosarcoma invading the left main pulmonary artery, The angiographic criteria of inoperability of patients with central pulmonary tumors are discussed.

Outpatient metrizamide myelography: prospective evaluation of safety and cost effectiveness

A group of 228 consecutive patients undergoing metrizamide myelography was prospectively evaluated for postprocedure symptoms. The observed prevalence of these symptoms concurs with previously reported inpatient studies, with the most common sequelae being exacerbation or onset of spine or extremity pain, headache, nausea, and paresthesia. Limitation of administered dose of metrizamide in lumbar myelography may slightly reduce the occurrence of common symptoms, but withdrawal of contrast medium at the completion of examination had no impact on their occurrence. There was a higher occurrence of paresthesia in cervical myelography, but otherwise there was no significant difference in symptoms between cervical and lumbar studies. Outpatient metrizamide myelography can be performed with relative safety with the potential for significant cost savings.

Radiology of the ileoanal reservoir

The radiology of the ileoanal reservoir based on a study of 50 consecutive patients is presented. Small-bowel obstruction (12%) and leakage at the ileoanal anastomosis (8%) were detected most commonly. Partial outlet obstruction from reservoirs fashioned from three segments of terminal ileum was noted radiographically as a common problem unique to this form of ileoanal reservoir. Superior mesenteric artery syndrome (6%), pelvic abscess (4%), pouch-vesicular fistula (2%), and several other problems were less frequent.

Digital subtraction angiography system evaluation with phantoms

Advances in digital subtraction angiography imaging demonstrate the need for critical evaluation of the performance of digital subtraction equipment. The design of a phantom set for noninvasive assessment of the imaging quality of digital subtraction equipment is described; components include a remotely controlled transport system and individual patterns to evaluate the contrast and detail properties of the image intensifier, low-contrast sensitivity and resolution of the system, geometric distortion of image, linearity, mechanical and electronic stability of equipment, and effects of bone and bowel gas on iodine perception. The performance of an add-on digital radiographic system is presented, along with radiation exposure levels at the image intensifier for a range of radiographic techniques.

Esophagogastric polyps: radiographic and endoscopic findings

Radiographic, endoscopic, and pathological findings were correlated in 20 patients with polypoid esophagogastric lesions. In 16 patients, pathological examination showed chronic inflammatory change and epithelial hyperplasia; the polyp was located on the gastric side of the squamocolumnar junction, usually in association with a prominent gastric fold, and probably represented a localized form of gastritis. In the other 4 patients, the lesion was adenocarcinoma. An inflammatory esophagogastric polyp may be differentiated from polypoid carcinoma when adequate radiographs are available and specific diagnostic criteria are followed. Endoscopic biopsy is recommended if the lesion does not fulfill the criteria of an inflammatory esophagogastric polyp.

Common bile duct calculi. 1. Surgical therapy

Multiple techniques are now available for management of the patient with retained or recurrent common bile duct calculi. The goal of treatment is extraction of calculi with the lowest possible incidence of morbidity and mortality, the lowest cost and least discomfort to the patient, and the best long-term results. The choice of therapy--surgical or nonsurgical--depends on several factors, including presence or absence of the gallbladder and a T tube, type of calculi, operative risk, accompanying conditions, and expertise available at a particular institution. The decision to explore the common bile duct at the time of elective cholecystectomy is based on clinical, operative, and cholangiographic information. A rigorous technique of surgical exploration that includes duodenal mobilization, choledochoscopy, and cholangiography is necessary. In selected patients, biliary enteric anastomosis decreases the incidence of retained or recurrent calculi.

Common bile duct calculi. 2. Nonsurgical therapy

Several nonsurgical methods of therapy are available for treatment of retained common bile duct calculi. These include percutaneous extraction, endoscopic extraction, dissolution, and endoscopic sphincterotomy. The method chosen depends on location and size of calculi, size of sinus tract, patient age, surgical risks, and other factors. In most cases, procedures can be carried out safely and successfully with few or no complications.

Iopamidol and meglumine diatrizoate: comparison of effects on patient discomfort during aortofemoral arteriography

Iopamidol was compared with Renografin-60 (meglumine diatrizoate, Squibb) in a controlled, randomized double-blind study of 40 patients undergoing peripheral arteriography for arteriosclerotic occlusive disease to determine which agent caused less discomfort. Each patient was evaluated for objective signs of discomfort and subjective feelings of pain and heat. Monitoring was achieved by multiple physical examinations, chemical tests, electrocardiograms, and intra-arterial pressure recordings. It is concluded that iopamidol is safe and causes significantly less patient discomfort than Renografin-60.

Anorectal herpes: radiographic findings

Radiography revealed aphthous ulcers, plaquelike erosions, and deep collar button ulcerations in a patient with herpes involving the rectum and the sigmoid colon. It is concluded that herpes simplex virus should be added to the list of disease entities that produce aphthous and collar button ulcerations.

Small-bowel varices demonstrated by enteroclysis

Small-bowel varices causing significant bleeding were demonstrated with the aid of enteroclysis in a patient with portal hypertension caused by alcoholic cirrhosis. Bleeding esophageal varices were ruled out by endoscopy.

Unusual thoracoabdominal duplication associated with pancreaticopleural fistula

The clinical case is presented of a 16-yr-old patient with thoracoabdominal duplication that communicated with the main pancreatic duct and the right pleural cavity and resulted in pancreaticopleural fistula. Although abdominal duplications communicating with the pancreas have been described before, to our knowledge, such an anomaly with intrathoracic extension has never been reported. Pleural effusions of high amylase content and surgical management of thoracoabdominal duplications are discussed.

Hemiazygos vein as a cause of posterior indentation of the esophagus: a case report

The hemiazygos vein crosses the midline at the level of D8 between the esophagus and spine to join the azygos vein. Any condition causing dilatation, from either obstruction or collateralization, can dilate the hemiazygos vein and produce posterior indentation of the esophagus. This vein is collapsible so it can easily be wedged between the esophagus and thoracic spine. Although various causes of indentations on the posterior wall of the esophagus have been described, we are not aware of any previous report of an esophageal impression from a dilated hemiazygos vein and therefore report such a case.

The choledochocele: correlation of radiological, clinical and pathological findings

Two cases of choledochocele are presented and 14 cases in the literature reviewed. Choledochocele is defined as a herniation of the common bile duct into the duodenum. This entity is distinguishable radiographically from duodenal diverticulum and duodenal duplication cyst by filling during cholangiography but not during upper gastrointestinal series. The duodenal diverticulum fills on upper gastrointestinal series but not on cholangiography. The duplication cyst will not fill with either method.

Intravenous cholangiography: optimum dosage and methodology

Cholangiography was performed in 442 patients using four dosage regimens of Cholografin: (a) a single-dose, full-strength injection in 10 minutes (150 examinations), (b) two dilute (76 examinations) or very dilute single doses (71 examinations) infused in 30 minutes, and (c) one dilute double dose infused in 30 minutes (145 examinations). Results showed that the double-dose infusion gave maximum visualization, followed by the single-dose injection and the two single-dose infusions. With the double-dose method, both the reaction rate and the incidence of SGOT elevation were twice that seen with any single-dose method, making the single-dose injection the procedure of choice despite slightly lower opacification.