Acute liver failure secondary to metastatic liver infiltration: case report and review of the literature

We present the case of a patient who died from multiple organ failure due to acute liver failure as a result of malignant hepatic infiltration by an adenocarcinoma. A review of the literature revealed that the clinical picture, laboratory examination, and imaging studies do not contribute to the diagnosis of this rare cause of liver failure. Therefore, liver biopsy should be considered early in the process, as this diagnosis is a contraindication for orthotopic liver transplantation.

Pylephlebitis complicating peridiverticulitis without hepatic abscess: early detection with contrast-enhanced CT of the abdomen

Pylephlebitis is a very rare and dangerous complication of inflammatory abdominal processes, mainly appendicitis (1) and diverticulitis (2).We describe a case of peridiverticular inflammation leading to a extensive phlebitis of the adjacent sigmoid vein, extending to the inferior mesenteric vein up to the proximal portal vein, with distal embolus into the left portal vein. Contrast CT and multiplanar reconstructions allowed early diagnosis, and with antibiotic and anticoagulation therapy, no liver abscess developed.

Anteromedial meniscofemoral ligament of the knee: CT and MR features in 3 cases

We report 3 cases of AnteroMedial MeniscoFemoral Ligament (AMMFL) fortuitously demonstrated during knee imaging in three patients. This rare normal variant of insertion of the anterior horn of the medial meniscus consists of an anomalous fibrous band distinctly covering the whole length of the anterior cruciate ligament to attach the anterior horn of the medial meniscus to the posterolateral wall of the femoral intercondylar fossa. AMMFL was diagnosed during arthro-CT in two patients and clearly identified during knee MR imaging in a third patient. The two cases demonstrated during arthro-CT--one prospectively and the other retrospectively--were confirmed during therapeutic arthroscopy. We illustrate the anomaly, discuss its controversial clinical significance and review the literature.

Transient and rapidly resolving intrahepatic portal gas: CT findings

Hepatic portal gas (HPG) has historically been associated with high (75% or over) mortality rates related to abdominal dramatic conditions and has served as an indicator for urgent exploratory laparotomy. Over the last two decades, the greater availability and higher speed of use of CT as well as improvement in the management of critically ill patients have increased the sensitivity of imaging HPG. HPG has been found associated with a broad range of diseases, some of which are benign and do not necessarily require urgent exploratory laparotomy in the absence of signs of intra-abdominal acute condition or systemic toxicity. We present a case of transient and rapidly resolving HPG found in a 61-year-old male admitted with hypovolemic shock due to upper gastrointestinal occlusion. HPG rapidly resolved after resuscitation of the patient with intensive re-hydration and drastic decompression of the fluid-full stomach through a nasogastric tube. The physiopathology and causes of HPG are briefly reviewed and its potential clinical significance is resituated.

Ileal inflammatory fibroid polyp causing ileocolic intussusception

Inflammatory Fibroid Polyp (IFP) is an extremely rare tumour involving the gastrointestinal tract (GI) and especially the stomach and small bowel. It presents either as a solitary large or sessile lesion arising from the submucosa and despite a large size and sometimes infiltrating growth, the tumour is always benign and has a good prognosis. Histogenesis remains unknown and controversial. We report an ileal case presenting classically and typically with ileocolic intussusception. Diagnosis was made preoperatively with abdominal mdCT. The polyp itself does not have noteworthy radiological signs but must be included in the large essentially histological differential diagnosis of GI tumours.

Metastases of clinically occult testicular seminoma mimicking primary extragonadal retroperitoneal germ cell tumors

BACKGROUND

Whether extragonadal germ cell tumors develop primarily in the retroperitoneum or whether they are essentially metastases of a primary testicular tumor has long been debated and remains controversial.

PATIENTS AND METHODS

Three patients presenting with apparent primary extragonadal retroperitoneal germ cell tumors are reported. Ipsilateral testicular evaluation was extended with palpation, ultrasonography and finally histological examination.

RESULTS

The retroperitoneal extragonadal tumors were found during abdominal MSCT. It was a fortuitous finding in the two first patients.The third patient presented with abdominal pain attributed to necrosis of the large mass which was subsequently firstly drained through endoscopic ultrasound-guided transduodenal puncture. The seminomatous nature of the retroperitoneal tumors was obtained through transduodenal echoendoscopic-guided cytopuncture in the first case, celioscopic resection in the second case and delayed percutaneous CT guided biopsy in the third symptomatic case. The first two patients had a history of cryptorchidism with substantial clinical testicular atrophy; ultrasonography showed microlithiasis and a small intratesticular tumor in the first patient and an hypoechoic but rather homogeneous atrophic testis in the other; orchiectomy confirmed small seminomatous intratesticular tumors in the two cases. The third patient had an atypical hypoechoic area on testicular ultrasound and histopatholgy revealed a burn-out primary tumor.

CONCLUSIONS

So-called primary extragonadal retroperitoneal germ cell tumors are extremely rare and should first be considered as metastases of a viable or burned-out testicular cancer until proven otherwise. All ipsilateral testicular abnormalities revealed by the patient's history, clinical examination and mostly by testicular ultrasound must be treated adequately with orchiectomy because they may act as a sanctuary for later tumor growth.

Carcinoid tumor of the small intestine: MDCT findings with pathologic correlation

BACKGROUND

MDCT currently frequently represents the first choice modality for imaging in acute or subacute abdominal conditions implicating the small bowel. As a consequence, the MDCT features of intestinal carcinoid tumors and of their peculiar metastatic spread have to be known by abdominal radiologists.

PATIENTS AND METHODS

These features are described and illustrated in the retrospective review of seven proven cases of small intestine carcinoids diagnosed and treated in our institution. The findings are described and correlated with gross anatomy specimens.

RESULTS

The primary tumour clearly appeared as a contrast-enhancing intraluminal lesion in all cases except in one case in which the primary lesion remained unlocalized and in another in which the primary tumour finally appeared infracted at gross anatomy. The maximal tumoral enhancement was obtained in 3 patients imaged during the acute arterial phase. The diameter of the primary tumour ranged from 1 to 3 cm and all masses were ileal comprising one lesion in the proximal ileum, two in the medium ileum and three in the distal ileum. 6/7 patients had multiple prominent mesenteric nodal metastases, all also appearing as hypervascularised enhancing masses. In 4/7 patients the nodal metastases represented the major finding being much prominent and larger than the primary tumour. Signs of retractile mesenteritis with soft tissue stranding, retraction and stellate pattern of the mesentery were found around the mesenteric metastases in 5/7 patients and direct incarceration of vessels were found in 3 cases.

CONCLUSION

The analysis of the arterial phase of MDCT study appears primordial to detect the sometimes very small but intensively enhancing primary tumor and to delineate encasement or direct obstruction of mesenteric vessels frequently caused by enhancing nodal metastases which volume often exceeds that of the primary tumor. Secondary retractile mesenteritis, deformation or ischemia of bowel loops, and hypervascular hepatic metastases are typical associated findings.

Intraabdominal counter clockwise gastric volvulus incarcerated through a defect of the lesser omentum: CT diagnosis

We report the probably first case of incarcerated intra-abdominal gastric volvulus protruding through a defect of the pars flaccida of the lesser omentum. The 79-year-old woman presented with acute symptoms of upper gastrointestinal occlusion. Plain film radiographs, endoscopy and attempts at opacifying the upper alimentary tract failed to make the correct diagnosis. The definite preoperative diagnosis was achieved by mdCT thanks to high quality multiplanar reconstruction (MPR). In the reported case coronal oblique MPR views and vascular volume rendering views (VR) were of particular interest for the preoperative diagnosis.

Multidetector computed tomography features of linea arcuata (arcuate-line of Douglas) and linea arcuata hernias

The aim of the study was to estimate the prevalence of delineation of semi circular or linea arcuata (arcuate line of Douglas) (LA) during 64-row multidetector Computed Tomography (mdCT) of the abdomen and to illustrate the so-called linea arcuata hernia (LAH), a peculiar type of interstitial parietal hernia of the anterior abdominal wall consisting of an ascending protrusion of intraperitoneal structures under the LA. The mdCT abdominal wall anatomy of a continuous series of 315 unselected patients was retrospectively reviewed and explored with multiplanar reformations (MPR). Considering a grade 1 lesion (G1) as a single delineation of the LA due to minimal bulging of intraperitoneal fat, a grade 2 hernia (G2) as a substantial herniation under the LA and grade 3 hernia (G3) as a frank prominent herniation of peritoneal structures (essentially omental fat and/or intestinal loops), lesions of all types were found in 8.57% of patients with more than 81% of lesions being G1; this prevalence reached 14.97% in men but only 1.35% in women (M:F sex ratio 12.5:1); all lesions were found in patients older than 51 years and 76% of them were older than 71 years with a great majority of men. Most patients were absolutely free of symptoms related to theses abnormalities. The anatomy of the rectus abdominis sheath and LA are reviewed and the mdCT signs of LA and LAH are described and illustrated. In conclusion, 64-row mdCT can frequently delineate the linea arcuata (LA) and more rarely linea arcuata hernias (LAH), particularly in old men, but these abnormalities mostly represent fortuitous asymptomatic findings.

Direct 3D imaging of the knee menisci during 16-row multislice CT arthrography

The aim of this paper was to explore the possibility to obtain high quality 3D images of the knee menisci during 16-row multidetector (MDCT) CT arthrography and to illustrate the performances of 3D images versus classical multi-axial 2D reformatted views through the study of a continuous series of 322 unselected patients. Correct to excellent meniscal 3D images were technically available in 97.7% of cases. When compared with 2D reformatted views, the negative predictive value, positive predictive value, sensitivity and specificity of 3D meniscal images were respectively 98.9, 98.6, 98.6 and 98.9% for the medial meniscus (MM) and 100% for the lateral meniscus (LM). Available in most patients, convincing 3D images of knee menisci obtained during 16-row MDCT arthrography could probably become a new method of choice for optimal illustration of complex meniscal tears in the future. Alternatively, efforts should be done to promote the development of similar 3D imaging of the knee menisci during MR studies that are considered by many authors as the gold standard non-invasive imaging method of the knee.

Giant splenic artery aneurysm presenting as unusual cause of obstructive jaundice

Giant splenic aneurysms larger than 8 cm (GSAA) are rare and often asymptomatic but present an increased risk of dramatic rupture, a life-threatening complication. The management of these aneurysms is especially challenging. We probably report the first case of GSAA revealed by clinical mechanical jaundice due to direct compression of the biliary tree. The lesion was diagnosed during abdominal ultrasound in a 68-year-old patient but determination of the specific splenic origin and extensive anatomic preoperative evaluation were achieved by MDCT. The case illustrates the new high quality performances of MDCT in the evaluation of complex vascular abdominal situations and is presented with a brief review of the relevant literature.

Multidetector-row CT of renal arteries: review of the performances in normo- and hypertensive patients

OBJECTIVE

To justify and illustrate the advantages of multidetector-row CT (MDCT) as probably the most effective method for imaging of renal arteries and to debate the question of multiple renal arteries.

METHODS AND MATERIAL

The renal arteries of 158 hypertensive patients were investigated with 8-row and 16-row MDCT using a highly standardized protocol; the results were compared with those obtained in a group of 112 normotensive patients.

RESULTS

MDCT of the renal arteries was found technically safely interpretable in 97.4% of cases. Fibromuscular dysplasia was found in 7/156 hypertensive patients (4.66%) concerning 9 arteries (2.18%) and > 50% atherosclerotic stenosis (in term of reduction of the cross-sectional area) was found in 11/156 patients (7%) concerning 14 arteries (3.4%). Accessory renal arteries were found in 66/156 hypertensive patients (42.3%) implicating 84 kidneys (27%) and in 50/112 patients (44.6%) of the normotensive group implicating 67 kidneys (29.9%).

CONCLUSION

With a good protocol, MDCT of the renal arteries is technically interpretable in most patients and can safely rule out atherosclerotic stenosis and/or fibromuscular dysplasia. The systematic cine-review of the native millimetric reconstructions and volume rendering images are the most recommended methods. Direct axial MPR views of the arterial lumen are also possible permitting a precise calculation of the percentage of stenosis from the cross-sectional area of the artery, an advantage on DSA in cases of asymmetrical stenosis. Finally a very high prevalence of multiple renal arteries--the highest ever reported to our knowledge--is found and the prevalence appears similar in both hypertensive and normotensive groups; this high prevalence not only confirms and emphasises the very high sensibility and resolution of MDCT but also definitively disproves the hypothesis that multiple renal arteries could predispose to hypertension.

Renal pelvis haemangioma demonstrated by MSCT urography with ureteral compression and 3D reconstruction

A rare case of renal haemangioma of the renal pelvis is reported. The 40-year-old patient classically presented with recurrent hematuria. The small pyelic tumour was clearly delineated by msCT urography obtained during compression of the uretera with rubber balloons classically used during IVP In the absence of a definite histological diagnosis--pyeloscopy being unsuccessful--the patient underwent radical nephrectomy. The literature concerning renal haemangioma is briefly reviewed and the role of compression assisted msCT urography as a possible method for the detection of small pyelocaliceal tumours is emphasized.

Giant fatty Schmorl's nodes: CT findings in four patients

OBJECTIVE

To describe the CT features of an unusual type of lumbar Schmorl's node (SN) appearing as giant fatty lesion of the vertebral bodies.

DESIGN AND PATIENTS

>Four patients (4 men; mean age 48.5 years) collected during a 9-month period were examined with MDCT for unremarkable lumbar symptoms; none had relevant history of specific trauma during the last years preceding the CT.

RESULTS AND CONCLUSIONS

The CT findings had a similar showing: a central or para-central osteolytic lesion in contact with the upper end plate of the vertebra, occupying about two-thirds to three-quarters of the body height and being surrounded by a thin and well-delineated bony rim. There was a clear interruption of the superior vertebral end plate above the lesion and an almost normal height of the adjacent vertebral disk. The CT appearance suggested a uniform fat content which was confirmed by density measurements ranging from -20 to -30 HU. The origin remains unknown, but a parallel is drawn between giant fatty SNs and giant cystic SNs. Intravertebral disk herniation is likely to be the initial phenomenon, with a preponderant responsibility of the "secondary induced intramedullar tissular disorders" to constitute the final size of the lesion. One hypothesis could be a fracture of trabecular bone with secondary hemorrhage and cystic or fatty degeneration. Alternatively, intramedullary vascular disturbances may lead to foci of bone necrosis that heal by fibroblastic proliferation followed by mucoid or fatty degeneration. It is also possible that giant fatty SNs could represent end stage of giant cystic SNs.

Emphysematous epididymitis as presentation of unusual seminal vesicle fistula secondary to sigmoid diverticulitis: case report

This case report describes a sigmoid diverticulitis with torpid development, long-term symptoms of bladder irritability, and an emphysematous epididymitis caused by a direct seminal vesicle fistula. The diagnosis was suggested by scrotal ultrasound visualizing gas in the scrotum; the complex pelvic fistulous tract was specifically delineated by multislice computed tomography. This may be the first reported case of seminal vesicle fistula directly related to colonic diverticulitis and causing emphysematous epididymitis.

Synovial haemangioma diagnosed during knee arthro-CT

Synovial haemangiomas are uncommon lesions most frequently found in the knee. We report a case in the popliteal area fortuitously demonstrated during knee msCT arthrography in a young female. The diagnosis was made possible by the sharp enhancement of the tumor caused by the venous drainage of the contrast medium injected into the synovial cavity. The diagnosis was confirmed by msCT angiography and MRI.

Intraperitoneal fat focal infarction of the lesser omentum: case report

Intraperitoneal fat focal infarction (IFFI) represents a relatively rare acute abdominal condition essentially characterized by infarction and/or torsion of the greater omentum or an epiploic appendage. The spontaneous clinical evolution is favorable under medical treatment, and the imaging findings have been proved sufficiently typical to avoid unnecessary surgery in the great majority of cases. To our knowledge, we report the first case of IFFI of the lesser omentum. Despite the absence of definitive histologic proof, the diagnosis was possible through typical imaging findings extremely similar to those of more classic cases of IFFI but also through the spontaneous benign evolution.

The spectrum of vacuum phenomenon and gas in spine

Although true physical-chemical experimental proofs are lacking in the literature, numerous clinical reports have shown that many radiological manifestations of the so-called vacuum phenomenon (VP) only represent snapshots of a complex dynamic hydropneumatical continuum extending from true vacuum to gas and/or fluid and vice versa. In the great majority of cases, VP remains an incidental accessory or anecdotal finding but, nevertheless, it occasionally represents a useful clinical or radiological sign of critical importance for the understanding, clinical diagnosis, prognosis, and therapeutic implications of several spinal diseases. VP and gas collections have been described in segments of the spine including the disc space, Schmorl nodes and vertebral structures, the epidural and intradural spaces, synovial cysts, and facet joints. In this article the author discusses and illustrates many aspects of VP and gas in the spine through selected examples collected over an 18-month period of time.

Colour duplex sonographic and multislice spiral CT angiographic diagnosis of ulnar artery aneurysm in hypothenar hammer syndrome

We report a case of hypothenar hammer syndrome secondary to a thrombosed aneurysm of the ulnar artery in a 36-year-old patient presenting with pain due to compression of the ulnar nerve in the Guyon's canal. The initial diagnosis was made by colour Duplex sonography but complete assessment of the thrombosed aneurysm was performed by multislice spiral CT angiography (msCTa). This case illustrates the potential of msCT as an alternative to conventional arteriography.

Atypical retroperitoneal extension of iliopsoas bursitis

We report two rare cases of iliopsoas bursitis extending into the retroperitoneal space. The first lesion contained much gas, mimicking a retroperitoneal abscess, and the second was responsible for atypical inguinal pain. The diagnosis was made by contrast-enhanced CT in both cases and arthrography in the first case. Iliopsoas bursitis in these two patients, it is hypothesized, extended into the retroperitoneum, at least in part, by way of intraneural or perineural structures.

Complicated Meckel's diverticulum diagnosed preoperatively in three cases by complementing CT with detailed us studies

The clinical and imaging features of Meckel's diverticulum of the adult are reviewed through the report of three complicated cases, one presenting with perforation, the second with intestinal bleeding, and the third with intestinal occlusion due to phytobezoar impaction. Intradiverticular heterotopy of gastric mucosa was the responsible common denominator for the first two cases. Intradiverticular calcified entheroliths were also found in the second case. Obstruction due to a phytobezoar as observed in the third case is a very rare presentation. This report clearly emphasizes and encourages the approach of this difficult diagnosis by combined CT and US imaging.

Gastric ulcer penetrating the anterior abdominal wall: ultrasound diagnosis

We report two rare cases of penetration of the anterior abdominal wall by gastric peptic ulcers. The full diagnosis was made by ultrasound, which showed similar findings: sharply delineated, hyperechoic craters clearly traversing the gastric wall and covered by hypoechoic inflammatory components of the abdominal wall. Because ultrasound is increasingly used as a primary procedure for evaluation of abdominal complaints, efforts should be directed toward exploring the accessible portions of the gastric and duodenal walls to detect peptic ulcer disease and its complications.

Lumbar radiculopathy caused by a tunneling transvertebral Schmorl's node

We report a rare case of lumbar spinal radiculopathy caused by a tunneling Schmorl's node originating from the superior endplate of the L3 vertebra of a 75-year-old patient and penetrating the spinal canal through the posterior wall of this vertebra. This case highlights recent reports emphasizing the clinical pain syndromes possibly associated with Schmorl's nodes.

[Pictorial essay. Infarction of the greater omentum: can US and CT findings help to avoid surgery?]

Infarction with or without torsion of the greater omentum is an uncommon but well recognised acute abdominal condition which was seldom diagnosed preoperatively before the widespread clinical use of US and CT. The aetiology is unknown and speculative. In most cases the pathology is right sided and clinical presentation consists of an acute or subacute flank pain with mild peritonism usually evoking appendicitis or cholecystitis. Recently, US and CT have proved to provide sufficiently typical, consistent and well-recognizable features to avoid unnecessary surgery. We report on six typical -five right sided and one left sided- cases investigated with CT and US. Two patients underwent surgical treatment, one because the usually spontaneous regression of the entity was ignored and the other because of extremely severe clinical symptoms. In the other four patients, conservative medical management was preferred and successful. Even though US may be efficient if performed by a well-trained echographist, CT appears to be the procedure of choice as it is operator independent and reliable for excluding mimicking surgical conditions or associated pathology.

Hyperechogenicity of medial gastrocnemial veins during ultrasound scanning of the calf in sitting patients: a normal variant

The goal of this study was to evaluate the prevalence and significance of the high echogenicity of blood frequently encountered in medial gastrocnemial veins (MGVs) during venous ultrasound scanning of the calf in sitting patients. Using a commercially available multi-frequency linear probe an experienced radiologist prospectively analysed a series of 97 legs from 59 patients referred to the ultrasound department for various clinical reasons; echogenic ambulatory outpatients being free of calf venous thrombosis were only considered. Hyperechogenicity of blood in MGVs was visible in 67 of 97 calfs (69%); it was discrete or moderate in 23 calfs (23.7%) and intense in 44 calfs (45,36%); 97% of these 67 calfs contained large MGVs whose diameter was at least twice that of the other muscular veins. The "washing out" manoeuvre applied to these veins by direct compression with the probe was effective to prove their normal permeability; after releasing of compression, hyperechogenicity was spontaneously restored in a mean time of 47.45+/-16.85 s. Because of a very low flow and a diameter commonly larger than other muscular veins, MGVs probably frequently reach a sufficiently low shear rate to promote aggregation causing echogenicity of blood when patients are examined in a sitting position. For this reason, hyperechogenicity of MGVs, instead of being a manifestation of local stasis, represent a reversible physiological normal variant. Nevertheless, the careful dynamic compression of these veins during ultrasound scanning is necessary to distinguish this normal variant from deep venous thrombosis.