Abstract: This article illustrates the various aspects of locoregional spread of cutaneous melanoma, as imaged with grayscale ultrasound (US) and Doppler techniques. High-resolution US allows recognition of small, clinically occult melanomatous foci within the skin and lymph nodes. Consequently, it plays a major role in locoregional staging and follow-up of patients with cutaneous melanoma. We discuss the possibilities and limitations of US in the initial staging (primary melanoma, satellite metastasis, in-transit metastasis, and lymphadenopathy), selection for sentinel lymph node biopsy procedure, patient follow-up, detection of recurrence, and US-guided intervention.
Abstract: The objective of this study was to evaluate the concordance of US and contrast-enhanced US (CEUS) with CT in the assessment of solid organ injury following blunt trauma. Patients underwent complete US examination, including free fluid search and solid organ analysis. CEUS followed, using low-mechanical index techniques and SonoVue. CT was performed within 1 h. Among 156 enrolled patients, 91 had one or more abnormalities (n = 107) at CT: 26 renal, 38 liver, 43 spleen. Sensitivity, specificity, and accuracy for renal trauma at baseline US were 36%, 98%, and 88%, respectively, after CEUS values increased to 69%, 99%, and 94%. For liver baseline US values were 68%, 97%, and 90%; after CEUS were 84%, 99%, and 96%. For spleen, results were 77%, 96%, and 91% at baseline US and 93%, 99%, and 97% after CEUS. Per patient evaluation gave the following results in terms of sensitivity, specificity and accuracy: 79%, 82%, 80% at baseline US; 94%, 89%, and 92% following CEUS. CEUS is more sensitive than US in the detection of solid organ injury, potentially reducing the need for further imaging. False negatives from CEUS are due to minor injuries, without relevant consequences for patient management and prognosis.
Abstract: PURPOSE: Cystic breast lesions with a nonsimple appearance, either complicated or complex, pose unique diagnostic difficulties, in part owing to their potentially malignant nature. Current ultrasound classification systems are based on morphostructural aspects only. The objective of this paper is to highlight the adjunctive role of Doppler techniques. MATERIALS AND METHODS: Over a 1-year period, we prospectively evaluated 45 women with atypical breast cysts of type IV, V or VI according to the Chang classification. Forty patients were symptomatic, whereas the cyst was discovered as an incidental finding in five cases. Our assessment included morphostructural, angioarchitectural and flowmetric aspects. RESULTS: Twenty-three nontumoural lesions were managed conservatively. All 19 type-IV cysts and all four type-V cysts according to the Chang classification showed absence of signal flow at colour Doppler imaging. Among the 22 tumoural lesions, there were eight papillomas, one atypical ductal hyperplasia and 13 carcinomas. The eight papillomas showed single (four cases) or multiple (four cases) mural projections. The atypical ductal hyperplasia showed a single parietal nodule. Among the 13 carcinomas, patterns included mural projections in 11 cases, eccentric cystic wall thickening in one and coarse intracystic septa in one. Cystic content appeared clear in six papillomas and in the case of atypical ductal hyperplasia, whereas it exhibited fine echoes in two papillomas. Among the carcinomas, cystic content showed coarse echoes in two cases and fine echoes in 11. Intralesional calcifications were seen in three carcinomas. Posterior enhancement was present in all carcinomas, whereas none showed posterior shadowing. In three carcinomas, some small solid satellite nodules were evident. Colour Doppler imaging showed lack of flow in four papillomas and subtle flow in the remaining four papillomas and in the atypical ductal hyperplasia. All 13 carcinomas showed diffuse vascularity, with multiple sparse vessels and multiple vascular poles. The resistive index, measurable in 4/8 papillomas, was 0.43 on average. Spectral analysis was measured in all carcinoma cases, yielding a mean resistive index of 0.71. CONCLUSIONS: Intracystic breast tumours exhibit distinctive morphostructural and colour Doppler features that allow effective differentiation from nontumoural cysts. Frequently, a presumptive differentiation between papillomas and carcinomas can be achieved. Absence of flow signals represents an additional criterion for complicated/complex cysts, allowing conservative management. Vascularity indicates the need for excision or biopsy of the solid projections, even in cases with negative cytology.
Abstract: OBJECTIVE: The purpose of this study was to report and analyze a new contrast-enhanced ultrasonographic (CEUS) imaging finding, the transient hepatic echogenicity difference due to perfusion changes, using computed tomography (CT) as a reference standard. METHODS: We retrospectively investigated the records of patients evaluated in a 2-year period, selecting those who had undergone both CT and CEUS within 15 days, who had CT evidence of a perfusion abnormality, and who had had a CEUS study that included the malperfused parenchymal area. RESULTS: There were 30 patients with 44 hepatic perfusion changes on CT scans (28 around liver focal lesions and 16 unrelated to focal lesions). Retrospectively, CEUS allowed recognition of 21 of 28 perifocal transient hepatic attenuation differences (THADs), 6 of 10 subsegmental THADs, 2 of 3 segmental THADs, and 1 of 3 lobar THADs. Only some of these abnormalities had been identified at the original CEUS examinations: 0 of 3 lobar THADs, 1 of 3 segmental THADs, 2 of 10 subsegmental THADs, and 16 of 28 perifocal THADs. CONCLUSIONS: Contrast-enhanced ultrasonography can show hepatic perfusion abnormalities similar to those well known from CT literature, although with a lower sensitivity. Knowledge of this transient hepatic echogenicity difference phenomenon may be relevant for avoiding incorrect image interpretation or incorrect tumor size measurement and for eventually identifying occult vascular disorders such as venous thrombosis or fistulas.
Abstract: MRI is the standard modality in the pre- and post-treatment evaluation of patients with rectal cancer, particularly in those cases with locally advanced disease. We routinely employ a superparamagnetic iron oxide (SPIO) contrast enema to distend the rectal lumen and achieve maximal tumor-to-lumen contrast gradient. This practice also allowed the identification of a fistula in 24% of patients treated for rectal cancer. Contrast agent-related low intensity signal could be seen filling the tract and eventually opacifying surrounding organs (i.e., vagina) or collections (i.e., presacral abscess). Fistula formation after radiochemotherapy and surgery for rectal cancer is not uncommon. MRI with dark lumen contrast enema allows an effective demonstration of this complication in a high number of patients.
Abstract: Contrast-enhanced sonography (CEUS) is a recently introduced, promising technique in the evaluation of the kidney. CEUS allows real-time assessment of normal and abnormal renal perfusions. As a consequence of the macrocirculation analysis allowed by Doppler techniques, it is possible to obtain real-time information about microcirculation. US contrast media are not nephrotoxic and can be employed safely, even in subjects with impaired renal function. There are several clinical scenarios where CEUS may play the role of a low-cost, scarcely invasive tool, including renal tumors (with special reference to small, indeterminate masses, i.e., differentiation between carcinoma and angiomyolipoma), renal atypical cystic masses (i.e., differentiation of malignant from benign cysts and follow-up of cystic lesions managed conservatively), renal infarction, renal infections, and renal injuries. In addition, CEUS can be useful in the assessment of renal pseudotumors (including any case with possible renal mass on conventional US imaging) and has been employed in radiofrequency ablation guidance. This pictorial review illustrates the CEUS findings recognizable in a wide spectrum of renal disorders and discusses the strengths and limitations of renal imaging with CEUS.
Abstract: OBJECTIVE: The purpose of this glossary is to offer an updated guide to the correct terminology for contrast-enhanced sonography. METHODS: This report was prepared by a panel of radiologists from the Sonography Section of the Italian Association of Medical Radiology. A leading author prepared a list of terms based on a comprehensive literature survey. The draft was analyzed by 3 experts on the topic of contrast-enhanced sonography. These reviewers reached a consensus and prepared the final version. RESULTS: A list of 137 terms is included. These terms are briefly defined. Their proper application is discussed, with special reference to potential misleading uses. CONCLUSIONS: Contrast-enhanced sonography is a relatively new diagnostic tool, now entering clinical practice in several countries. Use of appropriate, universal terminology is mandatory in the scientific setting to allow comparison between different published experiences. Additionally, use of clear, standardized terminology is necessary in the clinical setting to facilitate report understanding by the referring physician. Standardized, nonequivocal nomenclature may also help future diffusion of sonographic contrast media in countries where their application is still not approved.
Abstract: Active contrast medium extravasation is a recognized and important angiographic and computed tomographic (CT) sign of bleeding. It is an indicator of active, ongoing, and potentially life-threatening hemorrhage and, hence, of the need for an immediate surgical or interventional treatment. Sonography (US) is frequently used as the first imaging option for screening patients with traumatic and nontraumatic abdominal emergencies. Owing to the current possibilities of low-mechanical index, real-time, contrast-specific systems, it is now possible to detect a contrast leakage by using US. This finding opens new possibilities in the assessment and management of several abdominal emergencies, including trauma (initial workup and monitoring), spontaneous hematomas, and rupture of aneurysms or masses. This article describes the technique, findings, possibilities, and limitations of contrast-enhanced US in the evaluation of active abdominal bleeding.
Abstract: Sonography is frequently the first imaging modality employed to evaluate the spleen. Nevertheless, splenic abnormalities frequently determine subtle changes in echogenicity and may be overlooked. Additionally, splenic disorders have a nonspecific appearance, mostly appearing as hypoechoic defects. Difficulties in differential diagnosis are not uncommon, with splenic infarctions resembling, for example, focal lesions. Color Doppler is usually of limited additional value. Instead, the spleen is optimally suited for contrast-enhanced sonography, being superficial, small, and homogeneous, and showing intense and persistent contrast enhancement. Scarcely evident abnormalities become evident after contrast medium injection. Additional information can be obtained in many clinical scenarios, including blunt trauma, left flank pain, lymphoma, and incidental detection of splenic abnormalities.
Abstract: BACKGROUND: Optimal treatment of large-sized hepatocellular carcinoma (HCC) is still debated, because percutaneous ablation therapies alone do not always achieve complete necrosis. OBJECTIVE: To report our experience in the treatment of patients with HCC larger than 4 cm in diameter by combined percutaneous ethanol injection and radiofrequency thermal ablation. METHODS: In a 5-year period there were 40 consecutive patients meeting the inclusion criteria (24 men and 16 women; age range 41-72 years, mean 58 years). These subjects had a single HCC larger than 4 cm. Twelve subjects also had one or two additional nodules smaller than 4 cm (mean 1.2 nodules per patient). Patients were submitted to one to three sessions consisting of ethanol injection at two opposite tumor poles (mean 12 ml) and then of radiofrequency application through one or two electrodes placed at the tumor center (mean treatment duration 30 min). RESULTS: Complete necrosis was obtained in all cases with one to three sessions (mean 1.3 sessions per patient). All patients experienced pain and fever but one only subject had a major complication requiring treatment (abscess development and fistulization). Overall follow-up was 7-69 months. Two patients showed local recurrence and 9 developed new etherotopic HCC nodules. Seven subjects died during follow-up while 33 were free from recurrence 8-69 months after treatment. CONCLUSION: A combination of ethanol injection and radiofrequency ablation is effective in the treatment of large HCC.
Abstract: From January 2003 to April 2005 we studied 25 lymphoma patients (10 with HD, 4 with low-grade NHL, 6 with high-grade NHL and 5 with chronic lymphatic leukaemia; 14 men, 11 women, age range 28-79 years). After a baseline US study we rapidly injected 4.8 mL of the second-generation microbubble contrast agent SonoVue (Bracco, Italy). Contrast enhanced studies were carried out with the contrast-specific software named Contrast Tuned Imaging (Esaote, Italy) using a continuous, harmonic acquisition and a low acoustic pressure. The CS-US findings were correlated with results of standard tools, including CT, MRI, US follow up. CS-US revealed correctly 47 out of the 52 lesions identified by CT scan, in the absence of false positive findings (sensitivity = 90%; Specificity = 100%, in comparison to CT scan). Complete concordance in evaluating the lesion extension of the CS-US in respect to CT was 88%, while underestimate occurred in 9% and overestimate in 3% of cases. On the contrary, basic sonography defined correctly the dimensional alteration in 52% of the cases, underestimated in 35% and overestimated in 13%, thus showing significantly lower accuracy (chi-square = 30.0, p < 0.001). In our experience, CS-US was superior to conventional sonography even from a qualitative point of view.
Abstract: Recent advances in contrast material-enhanced ultrasonography (US) mainly include (a) development of low-acoustic-pressure (low-mechanical-index) harmonic software, capable of obtaining real-time images without disrupting contrast material microbubbles, and (b) commercialization of new contrast media ("second-generation" contrast media), capable of producing intense echo signals in this low-mechanical-index setting. With use of low-mechanical-index continuous-mode contrast-enhanced US, the circulatory kinetic models of various focal liver lesions can be displayed dynamically. Hepatic lesions usually have typical perfusion characteristics and enhancement patterns through the various phases of parenchymal enhancement, which helps characterize lesions and, in most cases, allows definitive diagnosis, even among lesions that exhibit very similar baseline appearances. Because of the use of harmonic technologies at low emission frequencies, there is some loss of spatial resolution and overall image quality, typically resulting in a grainy appearance. In addition, lesion depth affects the detectability of vascularity to some degree in that poor signal arises from deep-seated lesions. Moreover, liver attenuation (eg, in patients with steatosis or chronic liver disease) further reduces the sensitivity of contrast-enhanced US. Nevertheless, with its unique capacity to provide images in real time, low-mechanical-index contrast-enhanced US is the dynamic imaging modality of choice in the differential diagnosis of focal liver lesions.
Abstract: OBJECTIVE: Combined use of low-mechanical-index technologies and non-air-filled contrast media allows real-time sonographic assessment of the spleen. This pictorial essay focuses on several aspects of contrast-enhanced sonography of the spleen, including examination technique, clinical indications, normal findings obtained through all vascular phases, abnormal findings (splenomegaly, infarction, abscess, benign tumors, lymphoma, metastasis, injuries, and accessory spleen), limitations, and pitfalls. CONCLUSION: Real-time, contrast-enhanced sonography is a novel technique allowing depiction of a wide range of splenic abnormalities.
Abstract: OBJECTIVE: We describe the contrast-specific sonography features of ruptured abdominal aortic aneurysm, and we hypothesize that this technique would be useful for emergency imaging of patients with suspected aneurysm rupture. CONCLUSION: We used contrast-specific sonography to assess eight patients with ruptured abdominal aortic aneurysm. Five of these cases were correlated with CT findings. We found that contrast-enhanced sonography can reveal features specific for ruptured aortic aneurysm without causing a significant delay in surgery. This technique may be as effective as CT but may allow a more rapid and noninvasive diagnosis, especially when sonography can be performed bedside.
Abstract: OBJECTIVE: The purpose of this study was to report our initial experience in the assessment of liver trauma with real-time contrast-enhanced sonography (CES). METHODS: From January 2000 to December 2003, there were 431 hemodynamically stable patients evaluated with sonography for blunt abdominal trauma. Among these patients, 87 were selected to undergo second-level imaging, consisting of CES and computed tomographic (CT) evaluation. Indications for further assessment were baseline sonographic findings positive for liver injury, baseline sonographic findings positive for injury to other abdominal parenchyma, baseline sonographic findings positive for free fluid only, baseline sonographic findings indeterminate, and baseline sonographic findings negative with persistent clinical or laboratory suspicion. RESULTS: There were 23 hepatic lesions shown by CT in 21 patients. Peritoneal or retroperitoneal fluid was identified in 19 of 21 positive cases by all 3 imaging modalities. Liver injury was found in 15 patients on sonography and in 19 on CES. Contrast-enhanced sonography compared better than unenhanced sonography with the criterion standard for related injury conspicuity, injury size, completeness of injury extension, and involvement of the liver capsule. Both CES and CT showed intrahepatic contrast material pooling in 2 cases. All patients with false-negative sonographic or CES findings recovered uneventfully. CONCLUSIONS: Contrast-enhanced sonography is an effective tool in the evaluation of blunt hepatic trauma, being more sensitive than baseline sonography and correlating better than baseline sonography with CT findings. In institutions where sonography is regarded as the initial procedure to screen patients with trauma, this technique may increase its effectiveness. In addition, CES may be valuable in the follow-up of patients with conservatively treated liver trauma.
Abstract: Gastrointestinal stromal tumours (GIST) are the most common mesenchymal tumours of the alimentary tract. They normally involve the stomach, the small bowel, or the colon. Localisation within the oesophagus, rectum, mesentery, omentum, or retroperitoneum is less common. GISTs are immunohistochemically identified by the expression of the c-kit protein, which is not detected in other mesenchymal tumours. The role of imaging includes the detection (subjects with occult gastrointestinal bleeding, incidental recognition, etc.), characterisation, analysis of relations between mass and gastrointestinal wall, staging, prognostic assessment (recognition of signs of malignancy and unfavourable prognosis), and follow-up during specific treatment. Owing to the frequent exophytic growth of these lesions, differentiation of these tumours from nondigestive lesions of different nature is a common diagnostic problem. Imaging findings usually allow differentiation from gastrointestinal epithelial tumours but not from non-epithelial tumours, for which histological confirmation is necessary, in part to verify potential response to therapy. Smaller lesions, which are usually benign, tend to be well-defined, relatively homogeneous, and with intraluminal growth. Larger lesions normally show well-defined or ill-defined margins, inhomogeneous density both on unenhanced and on contrast-enhanced scans, with combined intraluminal/extraluminal growth and a tendency to spread to surrounding structures. Internal attenuation is often necrotic or clearly fluid. Signs of high-grade GIST include liver metastasis, gastrointestinal wall infiltration, large volume, irregular surface, ill-defined margins, inhomogeneous enhancement and peritoneal spread. Recurrences usually share the appearance of the larger, primary malignant GIST.
Abstract: OBJECTIVE: The purpose of this study was to categorize the sonographic findings seen in patients with a ruptured abdominal aortic aneurysm (AAA) and to describe 3 previously undescribed sonographic findings. METHODS: From January 1997 to December 2003, we evaluated 388 consecutive patients with an AAA (transverse aortic diameter >30 mm). Among these patients, 29 had surgical or computed tomographic demonstration of aneurysm rupture. The remaining 359 were asymptomatic and had no evidence of AAA rupture at follow-up. RESULTS: Findings recognized among 29 positive cases included AAA deformation (n = 12), luminal thrombus inhomogeneity (n = 20), clear interruption of a luminal thrombus (n = 5), retroperitoneal hematoma (n = 22), and hemoperitoneum (n = 11). In addition, 3 previously unreported findings were noted: an intraluminal floating thrombus layer (n = 8), a parietal hypoechoic focus due to aneurysm wall interruption (n = 3), and a para-aortic hypoechoic area adjacent to the bleeding side (n = 4). Aside from AAA deformation and thrombus heterogeneity, no other signs were recognized among subjects with a nonruptured aneurysm. CONCLUSIONS: In the past, sonography has been used mainly to rapidly confirm aneurysm presence in the clinical setting of a patient with a suspected rupture. Instead, this retrospective series shows how this imaging technique can frequently identify several direct and indirect signs of aneurysm rupture itself. Moreover, 3 new indicators of AAA rupture have been observed.
Abstract: BACKGROUND: Active contrast medium extravasation is a known angiographic and computed tomographic sign of ongoing, potentially life-threatening hemorrhage. Sonography (US) is frequently the first imaging option for screening patients with abdominal emergencies. Because of the current possibilities of low-mechanical-index, real-time, contrast-specific systems, it is possible to detect contrast leakage by using US. The purpose of this article is report our pilot experience in the evaluation of active traumatic and nontraumatic bleeding with contrast-enhanced US. METHODS: In a 2-year period, we performed 153 consecutive emergent contrast-enhanced US studies. Traumatic emergencies accounted for 83 examinations and nontraumatic emergencies accounted for 70. We used the contrast-specific mode Contrast Tuned Imaging and the contrast medium SonoVue. A 2.4- to 4.8-mL contrast medium bolus was injected with continuous US acquisition, starting immediately after contrast injection and lasting 1 to 6 minutes. RESULTS: Contrast extravasation was found in 20 cases (13%). These included spleen injury (n = 8), liver injury (n = 3), kidney injury (n = 1), abdominal aortic aneurysm rupture (n = 5), splenic angiosarcoma rupture (n = 1), postsurgical bleeding after abdominal aortic aneurysm repair (n = 1), and postsplenectomy bleeding (n = 1). Active extravasation appeared as a round, hyperechoic pool or as a fountain-like, hyperechoic jet. CONCLUSION: Our retrospective clinical study shows for the first time how US can detect contrast medium extravasation, a significant indicator of active hemorrhage and of need for prompt surgical or interventional treatment.
Abstract: BACKGROUND & AIMS: The aim of this study was to prospectively compare the diagnostic yield of wireless capsule endoscopy (WCE) and enteroclysis in evaluating the extent of small-bowel involvement in Crohn's disease (CD). METHODS: Thirty-one patients (20 men; mean age, 43 y) with endoscopically and histologically proven CD underwent enteroclysis as their initial examination, followed by WCE. The radiologist who performed the small-bowel enema was blinded to the results of standard index endoscopy, which included retrograde ileoscopy. Gastroenterologists were blinded to the results of enteroclysis at the time of interpretation of the WCE video. RESULTS: Abnormal findings were documented in 8 of 31 patients by using enteroclysis and in 22 of 31 patients by using WCE (25.8% vs. 71%, P < .001). In 16 patients with known involvement of the terminal ileum, the diagnostic yield of WCE vs enteroclysis was significantly superior (89% vs 37%, P < .001). In 15 patients without lesions in the terminal ileum, abnormal findings in the proximal small bowel were detected in 7 (46%) patients by WCE and only in 2 (13%) patients by enteroclysis (P < .001). The capsule detected all but 2 lesions diagnosed by enteroclysis. WCE detected additional lesions that were not detected by enteroclysis in 45% of cases. CONCLUSIONS: WCE is superior to enteroclysis in estimating the presence and extent of small-bowel CD. WCE may be a new gold standard for diagnosing ileal involvement in patients with CD without strictures and fistulae.
Abstract: Real-time, contrast-specific ultrasonography (US) uses low-mechanical-index, harmonic software to stimulate echo emission from resounding second-generation contrast medium microbubbles. At our institution, contrast-enhanced US is increasingly being used in the evaluation of acute abnormalities of the spleen, mainly to overcome some limitations of conventional (basic) US. This pictorial essay illustrates the appearance of several acute splenic lesions, both traumatic and nontraumatic, on contrast-specific US.
Abstract: OBJECTIVE: Low mechanical index contrast-specific sonography is a new technique that uses the harmonic capabilities of second-generation contrast agents to produce real-time contrast-enhanced gray-scale images. We describe the contrast-specific sonographic findings of pyogenic hepatic abscesses. CONCLUSION: Contrast-specific sonography was used to assess eight cases of aspiration-confirmed pyogenic liver abscesses. All cases were correlated with multiphasic helical CT findings. Continuous sonographic exploration allowed recognition of morphologic details not detectable on CT images. Contrast-specific sonograms showed features including rim enhancement, arteries along abscess margins and internal septa, dense and persistent septal enhancement, absent microcirculation in fluid and necrotic components, transient arterial phase hypervascularity around abscesses, and portal phase hypovascularity around abscesses. This constellation of findings is suggestive of liver abscess.
Abstract: Sonography (US) is the most commonly used tool in the assessment of patients with chronic liver disease. Nevertheless, small nodules can be overlooked. Moreover, even if the lesion is readily recognizable, difficulty persists in differentiating hepatocellular carcinoma (HCC) from pre-tumoral, dysplastic stages of nodule evolution. In addition, US is the main tool in guiding percutaneous ablation therapies for HCC and in evaluating patients after treatment, but changes are not specific and difficulties persist in recognizing residual tumor during and after the ablation procedure. Contrast-enhanced, gray-scale, harmonic US offers new possibilities in the imaging of liver tumors. The real-time, low-mechanical index technique employed in our institution allows a true dynamic assessment of the tumor during the various phases of contrast medium circulation. This pictorial essay focuses on typical and atypical appearances of HCC when imaged with contrast-specific, real-time US. Findings useful for lesion detection, differential diagnosis, posttreatment assessment, and follow-up especially are illustrated. The potential role of contrast-enhanced US in various clinical settings is emphasized.
Abstract: PURPOSE: To report our pilot experience in the evaluation of traumatic and nontraumatic emergencies with contrast-specific, continuous-mode sonography (US) and a second-generation contrast medium. MATERIALS AND METHODS: Between January 2002 and December 2003 we evaluated 126 acute patients by using real-time contrast-specific US: blunt abdominal trauma (76 cases), penetrating abdominal trauma (3), blunt scrotal trauma (1), right upper abdominal pain (10), left upper abdominal pain (9), epigastric pain (2), flank pain (5), right lower abdominal pain (2), scrotal pain (7), postoperative abdominal sepsis (1), post-biopsy haemorrhage (1), ruptured abdominal aortic aneurysm (8), postsurgical aortic bleeding (1). In all cases the radiologist performed a complete baseline US survey and then decided whether or not to add a contrast-enhanced examination. RESULTS: All contrast-enhanced sonographic studies were completed proving to be adequate for diagnostic purposes and without adverse reactions to contrast medium. There were 40 true negatives. The final diagnosis, obtained in 85 positive cases out of 86, was: splenic injury (28 cases), hepatic injury (3), renal injury (3), multiple injuries (3), pancreatic and portal vein injury (1), colonic-mesocolic injury (1), testicular trauma (1), hepatic abscess (9), hepatic ischaemia (1), gangrenous cholecystitis (1), splenic infarction (8), splenic haematoma abscess (1), renal infection (4), renal infarction (1), necrotizing pancreatitis (1), post-biopsy haemorrhage (1), appendicitis (2), peritoneal abscesses (1), testicular torsion (6), orchiepididymitis (1), iliac artery dissection (1), ruptured abdominal aortic aneurysm (6), aortic periprosthetic hemorrhage (1). Out of 85 positive cases, agreement between baseline US and contrast-specific US was absent in 8% of cases, low in 26%, intermediate in 42%, and high in 24%. Baseline US had 3 false positives. Relevance of contrast-specific US was absent in 17% of cases, low (additional data not relevant for patient management) in 26%, intermediate (relevant additional data not modifying patient management) in 34%, and high (additional data modifying patient management) in 23%. Agreement between contrast-specific US and the gold standards was absent in 0% of cases, low in 6%, intermediate in 38%, and high in 56%. Contrast-specific US had 2 false positive results. CONCLUSIONS: Real-time contrast-specific US is an effective technique in emergency imaging. Its role should not be considered as a replacement of CT (though in some instances it can be considered a valuable alternative) but as a useful integration of conventional US. By always having the opportunity to add contrast-enhanced imaging, in case of interpretation doubts or diagnostic difficulties, the radiologist can assess the emergency patient with improved confidence and skill.
Abstract: PURPOSE: To report our preliminary experience in the evaluation of the spleen using a real-time contrast-specific ultrasound module in combination with a second-generation contrast agent. MATERIALS AND METHODS: In a 7-month period, 55 patients (34 males and 21 females, aged 5-77 years) with spleen disorders were evaluated by means of contrast-enhanced ultrasound. Two patients were studied because of baseline evidence of an accessory spleen and both underwent ultrasound follow-up. Twenty-five patients were studied for abdominal trauma and results were correlated with those of helical CT. Three patients were examined for suspected splenic infarction and for all CT correlation was obtained. Finally, twenty-five subjects were examined for focal diseases, such as lymphomas (17 cases) and focal lesions (8 cases); contrast-enhanced US results were correlated with those of CT (8 cases), MRI (2 cases), ultrasound follow-up (8 cases), biopsy (2 cases) or splenectomy (1 case). After an initial baseline study, the contrast-enhanced examinations were carried out using a dedicated unit equipped with a continuous contrast-specific module at low acoustic pressure. The examination started immediately after rapid contrast injection and lasted approximately 4 minutes. In the comparison between baseline and contrast-enhanced ultrasound, the following aspects were considered: detection rate of parenchymal changes, lesion extent (equal to CT, under- or overestimated), and lesion conspicuity (lesion-to-parenchyma gradient, from 0 = absent to 3 = high). RESULTS: In the 2 patients with accessory spleen, an enhancement very similar to that of the adjacent parenchyma was present and a small vascular pedicle was noted. Among the trauma patients, 18 had a direct splenic injury and one showed splenic contraction and hypoperfusion due to shock. In 74% of cases, a peritoneal effusion was demonstrated both with baseline and contrast-enhanced ultrasound; perisplenic blood collections (58% of cases) were identified in 42% of patients by both baseline and contrast-enhanced ultrasound; post-traumatic infarction was always revealed by contrast-enhanced ultrasound (11% of cases) but never by baseline ultrasound; parenchymal injuries were detected with a sensitivity of 63% by baseline ultrasound and a sensitivity of 89% by contrast-enhanced ultrasound. Moreover, contrast-enhanced ultrasound revealed findings undetectable on conventional ultrasound: global splenic hypoperfusion in 2 cases (due to shock in one and pedicle avulsion in the other), intraparenchymal contrast collections in 21% of positive cases (as confirmed by CT), extrasplenic contrast leakage in 1 of 2 cases demonstrated by CT. Of the 3 cases of splenic infarction, baseline sonography only only identified two, whereas the contrast-enhanced examination clearly identified three. Contrast-enhanced ultrasound revealed 35 of 39 focal lesions in patients studied for Hodgkin's disease and splenic focal lesions. Baseline ultrasound had a lower sensitivity (23 lesions). Lesion extension shown by contrast-enhanced sonography was equivalent to that provided by standard methods in 88% of cases (underestimated in 9% and overestimated in 3%); baseline US correctly estimated lesion size in 52% of cases, under- and overestimating them in 35% and 13% of cases, respectively. Lesion conspicuity was graded as 1 (low) in 16%, 2 (moderate) in 67%, and 3 (high) in 17% of the cases identified by enhanced sonography. Baseline ultrasound was less effective: conspicuity was graded as 1 in 42%, 2 in 39%, and 3 in 19% of cases. CONCLUSIONS: The spleen is the ideal organ to be studied with second-generation contrast media due to its superficial location, high vascularity, small size and homogeneous texture. Contrast-enhanced ultrasound is a simple, poorly-invasive and accurate tool for the evaluation of splenic disorders. If our data are confirmed, it will be possible to reduce the use of more complex technologies such as CT and MRI.
Abstract: OBJECTIVE: To report our experience in the assessment of splenic trauma with contrast-coded sonography and a second-generation contrast medium. METHODS: From January to May 2002, 120 patients were studied with sonography for suspected splenic trauma. Twenty-five were selected for further imaging because of sonographic findings positive for splenic injury, findings positive for peritoneal fluid only, indeterminate findings, and negative findings with high clinical or laboratory suspicion. These patients underwent contrast-enhanced harmonic sonography and contrast-enhanced helical computed tomography. RESULTS: Among the 25 patients studied, 6 had no spleen trauma at initial and follow-up evaluation. One patient had a hypoperfused spleen without parenchymal damage, and 18 had splenic injuries; these 19 patients were considered positive. Hemoperitoneum was identified by sonography, contrast-enhanced sonography, and contrast-enhanced computed tomography in 74% of the 19 positive cases. Perisplenic clots were recognized in 58% of the cases by computed tomography and in 42% by baseline and enhanced sonography. Splenic infarctions were found in 11% of cases by contrast-enhanced sonography and computed tomography; none was found by unenhanced sonography. Parenchymal traumatic lesions were identified in 12 of 18 patients with splenic injuries by unenhanced sonography, in 17 cases by contrast-enhanced sonography, and in all 18 cases by contrast-enhanced computed tomography. A minimal splenic lesion was found in the single patient with a false-negative contrast-enhanced sonographic finding. Contrast-enhanced sonography correlated appreciably better than unenhanced sonography in detecting injuries and in estimating their extent. Findings undetectable on unenhanced sonography were also noted: splenic hypoperfusion in 11% of positive cases on both contrast-enhanced sonography and contrast-enhanced computed tomography, contrast medium pooling in 21% of cases on both contrast-enhanced sonography and computed tomography, and contrast extravasation in 11% of cases on computed tomography and 5% on contrast-enhanced sonography. CONCLUSIONS: Contrast-enhanced sonography is a promising tool in the assessment of splenic trauma. In institutions where sonography is used as the initial procedure, this technique may increase its effectiveness.
Abstract: Several conditions can clinically mimic renal colic. We assessed the accuracy of non-contrast-enhanced helical CT and of ultrasonography (US) in offering an alternative explanation for flank pain. In a 3-year period, 181 patients with acute flank pain underwent US and non-contrast-enhanced helical CT in a blinded sequence. Their efficacy in detecting both alternative causes of pain and additional findings unrelated to the pain was assessed in 160 cases with a confirmed diagnosis. An alternative cause was found in 23 cases (14%). US gave 4 false-negative results (1 acute appendicitis, 1 ovarian cyst torsion, 1 diverticulitis, and 1 papillary necrosis) and 2 false-positive results (1 acute pyelonephritis and 1 diverticulitis), with a 78% sensitivity and a 98% specificity for nonlithiasic causes. CT gave 5 false-negative results (1 complicated ovarian cyst, 1 pleuritis, 1 epididymitis, 1 acute pyelonephritis, and 1 papillary necrosis) and 1 false-positive (1 simple ovarian cyst described as a complicated lesion), resulting in a 74% sensitivity and a 99% specificity for diagnosing alternative causes. There were 130 additional US findings in 68 patients and 151 additional CT findings in 77 patients. A wide spectrum of findings can be identified in subjects imaged for flank pain. Non-contrast-enhanced helical CT and US have comparable accuracy in diagnosing causes other than stone disease.
Abstract: OBJECTIVE: The purpose of this study was to compare the accuracy of unenhanced helical CT with combined sonography and unenhanced radiography in patients with acute flank pain suggestive of ureteral colic. SUBJECTS AND METHODS: From January 1997 to December 1999, 181 consecutive patients with acute flank pain underwent unenhanced radiography, sonography, and unenhanced helical CT (protocol A). From January 2000 to December 2000, 96 consecutive patients arriving at the emergency department with acute flank pain were alternately submitted either to primary unenhanced helical CT (protocol B, 48 patients) or to unenhanced radiography and sonography with the addition of helical CT in unclear cases (protocol C, 48 patients). RESULTS: When compared with the diagnostic accuracy for ureterolithiasis of the combined sonography and radiography in the same group of subjects (protocol A), CT had a greater sensitivity (92% vs 77%), negative predictive value (87% vs 68%), and overall accuracy (94% vs 83%). Among patients who underwent primary CT (protocol B), we found three false-negatives (all with spontaneous stone passage) and no false-positives. Among patients initially examined with unenhanced radiography and sonography (protocol C), we found one false-positive (leading to patient admission and needless repeated radiographic and sonographic studies) and six false-negatives (all followed by an uncomplicated course and spontaneous passage); CT depicted four of these stones but did not result in change in treatment. Fourteen percent of the patients in protocol C required invasive treatment, but combined sonography and radiography showed stones and hydronephrosis in all these patients. CONCLUSION: Unenhanced CT was the most accurate modality for determining the presence of ureterolithiasis. The combination of abdominal radiography and sonography, however, yielded comparable results with no clinically important misdiagnoses and thus can be used as an alternative when CT resources are limited.
Abstract: BACKGROUND: To categorize the helical computed tomographic (CT) intrahepatic recurrence patterns of hepatocellular carcinoma (HCC) after treatment with percutaneous ablation procedures. METHODS: Double-phase helical CT studies of 67 patients with HCC recurrence were reviewed. The study population had undergone percutaneous ablation therapy procedures (multisession or single-session ethanol injection therapy, radiofrequency thermal ablation therapy, and interstitial laser photocoagulation therapy) for 120 HCC nodules. RESULTS: Four patterns were defined. (A) Enhancing tissue within the edge of the ablated nodule on arterial phase images (ingrowth): this pattern was seen in five treated lesions (4.2% of all treated nodules) in five patients (7.5% of all patients with recurrence) 3-7 months after treatment (mean = 4 months). (B) Enhancing tissue around the treated nodule but continuously to its border on arterial-phase images (outgrowth): this pattern was found in 12 (10%) treated lesions in 12 patients (18%) 3-6 months after ablation (mean = 4 months). (C) Enhancing tissue within the same segment of the treated nodule on arterial phase images (spread): this pattern was detected in 10 (8%) treated lesions in 10 patients (15%) 3-6 months after treatment (mean = 5 months). (D) Enhancing tissue within different segments from the treated nodule on arterial phase images (progression): this pattern was identified in 34 patients (51%) with 53 (44%) treated tumors 5-22 months after ablation (mean = 8 months). A mixed pattern was found in six subjects (9%) with seven (6%) treated nodules. Among the 61 patients with a nonmixed pattern, there were 85 treated nodules with persistent necrosis, 17 treated nodules with local recurrence (pattern A or B), and 107 new nodules due to nonlocal recurrence (pattern C or D). Portal phase enhanced images and especially unenhanced images showed a lower detection rate and a lower lesion-to-liver conspicuity score (for all patterns but mainly for pattern C). CONCLUSION: Four patterns of recurrence after percutaneous ablation procedures can be categorized on double-phase helical CT and are best depicted on arterial phase images. Knowledge of these patterns is relevant for early detection and may be helpful in understanding the recurrence mechanism.
Abstract: PURPOSE: Duplex Doppler ultrasound allows the evaluation of thyroid gland vascular flow by spectral analysis assessment. The objective of this prospective study was to employ Doppler ultrasound to evaluate the possible functional changes produced in normal subjects following intravenous iodized contrast medium injection. MATERIAL AND METHODS: The study was performed on 30 non-consecutive subjects, enrolled according to some inclusion criteria: male gender, age ranging between 19 and 70 years, absence of chronic liver disease, absence of thyroid disease, absence of sonographic changes in the thyroid gland, negative history for recent intravenous contrast medium administration. All patients were scheduled for a contrast-enhanced CT study. A non-ionic contrast medium (iomeprol) was employed at 350 mgI/mL concentration, 130-140 mL volume, and 2-4 mL/sec. injection rate. The Doppler ultrasound examination was carried out immediately before and about 30 minutes after the CT study. The systolic velocity, diastolic velocity, the resistive index, and the pulsatility index were measured at the level of one of the four thyroid arteries. RESULTS: In most cases a slightly increasing trend of the four parameters considered was noted but none of these showed a statistically significant change. The mean systolic velocity was of 33 cm/sec. in the basal measurement and of 39 cm/sec. in the post-contrast measurement. The variation was positive in 17 cases, negative in 12, and absent in 1. The mean diastolic velocity was of 13 cm/sec. in the pre-contrast evaluation and of 14 cm/sec. in the second evaluation. The change was positive in 14 cases, negative in 12, and absent in 4. The mean resistive index was of 0.55 in the basal analysis and of 0.59 in the post-contrast one. The variation was positive in 20 patients, negative in 9, and absent in 1. The mean pulsatility index was of 0.99 in the basal measurement and of 1.14 in the second measurement. The change was positive in 23 subjects, negative in 5, and absent in 2. CONCLUSION: Our series shows that no significant change in Doppler spectral analysis of thyroid flow is evident after administration of iodized contrast media, at least in euthyroid subjects and with the contrast doses and the examination intervals employed in our study. Doppler ultrasound is confirmed as an accurate and objective procedure in the evaluation of thyroid gland flow and may represent a useful tool in functional studies, as well as clinical applications in the assessment of thyroid gland disorders.
Abstract: Objective: To evaluate the efficacy and complications of interstitial laser photocoagulation (ILP) under ultrasound (US) guidance as a technique for focal ablation of liver tumors in patients with normal and impaired hepatic function. Patients and Methods: A total of 104 patients, 77 with 85 nodules of hepatocellular carcinoma on cirrhosis (29 in Child-Pugh A class, 43 in B e 5 in C class) and 27 patients with hepatic metastases (25 from colon, two from lung carcinoma) underwent ILP under US guidance. Depending on tumor size up to four needles were inserted in the tumor and multiple laser illuminations were performed in one or multiple sessions. Necrosis of the nodules was evaluated with triphasic contrast-enhanced CT. Results: Ninety-four patients underwent a single ILP session and nine patients two sessions. CT showed complete necrosis in 70 out of 85 HCC nodules in 65 treated patients and in 24 out of 31 patients with metastases. Three Child C class patients dropped out the control of efficacy by CT because of severe liver failure associated in one case with transient paralytic ileum. One of these patients died 2 months after treatment. Two patients with metastasis dropped the completion of the treatment because of complication occurred after the ILP session (one paralytic ileum, one gastric haemorrage). Conclusions: ILP under US guidance is effective in inducing complete necrosis in small and large liver tumors. Nevertheless, ILP can cause severe derangement of liver function in patients with advanced cirrhosis.
Abstract: BACKGROUND: Multiple-phase helical computed tomography (CT) has been regarded as the method of choice in the evaluation of patients with hepatocellular carcinoma (HCC) treated by nonsurgical procedures. The aim of this article was to report our experience in the assessment of nodular and parenchymal changes recognizable after various percutaneous ablation therapies. METHODS: We reviewed the studies of 116 consecutive patients with HCC treated with multisession percutaneous ethanol injection (56 patients, 98 nodules), single-session percutaneous ethanol injection (14 patients, 31 nodules), radiofrequency thermal ablation (32 patients, 48 nodules), and interstitial laser photocoagulation (14 patients, 25 nodules). CT had been performed 3-28 days after the last session (mean = 18 days) with unenhanced helical acquisition and with contrast-enhanced double- or triple-phase helical acquisition. RESULTS: Persisting neoplastic tissue was identified within 54.5% of the nodules. It was located centrally in 4.5% of these nodules, peripherally in 11%, and eccentrically in 84.5%, and its shape was crescent in 58%, globular in 24.5%, and other in 16%. On arterial phase scans, viable tumor was hyperdense in 97% of the lesions and isodense in 3%; on portal phase scans, the tumor was hyperdense in 20%, isodense in 28%, and hypodense in 52%; on delayed phase scans, the tumor was consistently hypodense. Tumor necrosis was always hypodense on contrast-enhanced scans. On unenhanced images, 7.4% of the nodules were undetectable. Nodule diameter appeared as unchanged in 53% of the nodules and as larger in 47%; its shape was unchanged in 54% and modified in 46%; its margins were unchanged in 36% and modified in 64%. A rim of granulation tissue was detected around 15% of the nodules, and a perilesional transient attenuation difference was detected in 21%. Perihepatic effusion was seen in 13% of the patients, segmental biliary duct dilation and local atrophy each in 9%, arterioportal fistula in 6%, portal vein thrombosis, subcapsular collection and pleural effusion each in 7%, hepatic infarction in 5%, and inferior vena cava thrombosis in 2%. CONCLUSION: Percutaneous ablation of HCC may cause several changes. Knowledge of their CT appearance is mandatory to correctly assess and manage this tumor.
Abstract: Nonsurgical treatment of hepatocellular carcinoma is used worldwide as a result of the early detection and slow growth of this tumor in patients with chronic liver disease. Multiple-phase helical computed tomography is a commonly used method for evaluating the main features related to percutaneous ablation procedures: nodular changes, tumor necrosis, parenchymal changes, complications, and tumor recurrence. Knowledge of all features recognizable after local ablation therapy is mandatory to avoid diagnostic pitfalls and to optimally assess treatment response.
Abstract: PURPOSE: To report our personal experience with the addition of contrast-enhanced multiphase helical CT to unenhanced CT (Lipiodol CT) in the evaluation of patients with hepatocellular carcinoma treated with chemoembolization and to analyze the present role of oily agent CT. MATERIAL AND METHODS: We retrospectively reviewed the examinations of 42 consecutive patients submitted to global chemoembolization over a 2-year period. CT was performed 18-30 days after the treatment. The Lipiodol CT study was carried out with volume acquisitions. We considered as nodules all well-defined areas with dense oily agent uptake; uptake itself was classified as: 0 = absent, I = lower than 10% of the tumor volume, II = lower than 50%, III = higher than 50%, IV = homogeneous. Contrast-enhanced helical CT was performed with the 2-phase technique in 28 patients and with the 3-phase technique in 14; we considered as nodules all well-defined and relatively homogeneous areas with hyperattenuation in the arterial phase and hypo-isoattenuation in the portal and/or delayed phase, or with hypo-isoattenuation in the arterial phase and in the portal and/or delayed phase. RESULTS: Lipiodol CT permitted to recognize 65 nodules (1-5/patient, mean 1.5), namely 15 grade I, 21 grade II, 20 grade III and 9 grade IV. Multiphase CT identified 6 additional nodules in 5 patients, 5 hypervascular and 1 hypovascular, and better assessed the correct morphology and volume of grade I nodules. Only 4 of 6 nodules missed on Lipiodol CT showed oily agent uptake after a new chemoembolization session. Moreover after retreatment, carried out in 6 of 9 patients with grade I uptake (11 nodules in all), we found persistence of the grade I pattern in 5 nodules, grade II in 5, and grade III in 1. CONCLUSION: Lipiodol CT may miss liver nodules and underestimate the volume of nodules with poor uptake. Though Lipiodol CT should still be considered slightly more sensitive than multiphase CT, in our opinion this technique has several limitations, as also shown in recent literature papers, and its clinical applications should be reduced. Multiphase helical studies may provide useful information and should be performed routinely in patients treated with chemoembolization. The present availability of alternative tools such as contrast-enhanced Doppler US and MRI should also be stressed and their potential role investigated.
Abstract: PURPOSE: The possibility of detecting contrast agent extravasation (i.e., active hemorrhage) with dynamic conventional Computed Tomography (CT) in patients with abdominal trauma has already been reported in small series. We report our experience in the demonstration of contrast material extravasation using helical CT; we also investigate the diagnostic and clinical value of this finding. MATERIAL AND METHODS: January 1997 to July 1998, we examined 41 consecutive patients with upper abdominal trauma. Twelve patients (29%) had contrast material extravasation. The examinations were performed with a helical unit and volumetric acquisitions (thickness 8-10 mm, pitch 1, reconstruction interval 5-8 mm). The intravenous contrast medium (350 mgI/mL, 130-140 mL) was administered with rapid infusion (2-2.5 mL/s, 40-50 s acquisition delay from bolus starting) and using a power injector. We reviewed the CT studies and clinical records of these 12 patients. Contrast agent extravasation was considered present when this finding, not recognizable on plain scans, showed equal attenuation to or higher attenuation than the vessels within the same level. Moreover we assessed leak site, CT appearance, the direct visualization of the involved vessel, the evidence of other abdominal or extra-abdominal injuries, the CT signs of hypovolemic shock, clinical and surgical data. For comparison, we finally evaluated 50 examinations performed with a conventional CT scanner in subjects with abdominal trauma. RESULTS: Active hemorrhage involved the abdominal wall in 1 case (intercostal artery), the solid organs in 4 (splenic in 2, hepatic in 1, of the middle hepatic vein in 1), the peritoneal cavity in 3 (splenic, midcolic, and gastroduodenal artery in 1 each), the retroperitoneum in 4 (renal pedicle in 2, renal parenchyma in 1, lumbar artery in 1). In all cases the site of contrast extravasation corresponded at surgery to the site of active bleeding. The pattern was localized in 10 cases and diffuse in 2. The involved vessel could be identified in 5 cases while in the other ones the origin could be inferred from the leakage site. Associated injuries of upper abdominal organs were seen in 11 of 12 patients and extra-abdominal trauma in 6. In 4 cases there were CT features of hypovolemia. One patient died during transport to the operating room and another after surgery, while all the others survived. Contrast extravasation was identified in 9 (18%) of the patients examined with a conventional CT unit. CONCLUSIONS: Active contrast material extravasation can be recognized with conventional CT scanners, though it has been considered a rare finding. Helical CT seems to increase the detection rate and especially to boost the radiologist's confidence in this diagnosis. Though active bleeding is identified in severely-injured subjects requiring urgent intervention and may be associated with findings of hypovolemic shock, it should not be considered itself as a negative prognostic factor. Contrast extravasation is due to ongoing hemorrhage and its detection is critical for urgent treatment. Accurate anatomical location permits to choose surgical management or transcatheter embolization and thus decreases time consumption for precise bleeding site identification.
Abstract: PURPOSE: To report our preliminary experience concerning the use of Doppler ultrasonography (DUS) techniques after intravenous injection of the galactose-based contrast agent Levovist in the assessment of hepatocellular carcinoma (HCC) treated with transcatheter arterial chemoembolization (TACE). The sonographic findings are correlated with those obtained using iodized oil (Lipiodol) helical computed tomography (CT). METHODS: For 7 months we studied 28 patients with cirrhosis and HCC (a total of 43 nodules) who had undergone TACE between 18 and 30 days previously. The lesions were investigated with color Doppler ultrasonography (CDUS) and power Doppler ultrasonography (PDUS), before and after infusion of the echo-contrast agent (300 mg/ml, maximum 1 injection for each nodule, administered at constant velocity within 60-90 sec), and with helical Lipiodol-CT (0-7 days after DUS). In the retrospective analysis, special attention was given to the Doppler signals related to pulsatile intra- and perinodular flow and to the detection of new vessels after contrast agent injection. The signal intensity was graded as 0 (absent), 1 (low), 2 (medium), or 3 (high), while its distribution was classified as peripheral, central, or diffuse. Oily agent retention on CT scans was assessed as 0 (absent), I (<10%), II (<50%), III (>50%), or IV (homogeneous). These scores were awarded separately, without knowledge of the other judgments. RESULTS: An hepatic global echo-enhancing effect was identified in all cases and always lasted long enough to allow an accurate analysis of all parenchymal lesions (at least 8 min). The signal scores could be evaluated in 39 of 43 HCCs, as follows: basal CDUS: grade 0 in 17 lesions, grade 1 in 16, grade 2 in 6; contrast-enhanced CDUS: grade 0 in 12 lesions, grade 1 in 10, grade 2 in 14, grade 3 in 3; basal PDUS: grade 0 in 15 lesions, grade 1 in 13, grade 2 in 9, grade 3 in 2; contrast-enhanced PDUS: grade 0 in 11 lesions, grade 1 in 9, grade 2 in 15, grade 3 in 6. Lipiodol-CT scoring was: grade 0 in 1 lesion, grade I in 7, grade II in 11, grade III in 9, grade IV in 11. In all but one nodule the difference between CDUS and PDUS scores, compared both with each other and with nonenhanced and contrast-enhanced examinations, was never greater than one grade. CONCLUSIONS: Contrast-enhanced DUS is a simple and fast procedure allowing a valuable, constant echo-enhancing effect of sufficient duration. DUS techniques, especially contrast-enhanced PDUS, offer an effective and realistic analysis of HCC nodules treated with TACE and show more evident agreement with Lipiodol-CT findings than baseline studies.
Abstract: PURPOSE: We investigated the yield of Helical CT in the study of lung vessels, the incidence of the angiogram sign and its actual value. MATERIAL AND METHODS: July 1997 to December 1998, we studied 30 cases of pulmonary collapse of different origin. We found 15 cases of passive collapse (10 from pleural effusion, 2 from diaphragmatic compression, 2 from traumatic pneumothorax, and 1 from isthmic aortic aneurysm), 12 cases of obstructive collapse (9 from bronchogenic carcinoma, 1 from mucoid obstruction, 1 from hilar lymphadenopathy, and 1 from mediastinal cancer), 2 cases of adhesive collapse and 1 case of round atelectasis. All the examinations were performed with the Helical technique during nonionic iodinated contrast agent injection (bolus, 300-350 mg/mL); we used an automatic injector set at 2-3 mL/s. We studied the images for the angiogram sign, that is hyperdense bands, usually longer than 2 cm, through the collapsed lung, which correspond to normal pulmonary vascular branches. RESULTS: The angiogram sign was found in 95% of passive (14/15) and in 80% of obstructive (10/12) collapses. However in 2 of those we also found some hyperdense spots referable to vessels seen on transverse slices. The angiogram sign was missing in 1 of 2 adhesive collapses because of vascular distortion from irradiation-related fibrosis. The "comet-tail" vascular pattern was seen in round atelectasis. We had no cases of cicatricial collapse. CONCLUSIONS: Thanks to its fast acquisition capabilities, Helical CT well depicts peak vascular enhancement, which permitted identification of the angiogram sign in several pulmonary collapse cases. Thus, this sign becomes even less specific, and just one of the signs of pulmonary consolidation.
Abstract: PURPOSE: Spiral imaging has dramatically increased the diagnostic capabilities of Computed Tomography (CT) in the evaluation of small hepatocellular carcinomas (HCCs, O < 3 cm). We report our experience with multiple-phase CT of small HCC relative to both examination technique and lesion patterns. We compared the yield of biphasic (arterial-dominant + portal-dominant phases) and triphasic (arterial-dominant + portal-dominant + delayed phases) and also reviewed the literature for a meta-analysis of the techniques used. MATERIAL AND METHODS: December 1996 to July 1998, forty-eight patients with small nodular HCCs were examined--98 nodules in all (range 1-9, mean 2 per patient). After baseline CT, a nonionic contrast agent (350 mgI/mL, 130-140 mL, 4 mL/s) was administered through a power injector and a 16-gauge needle. Biphasic volume images were acquired in 19 subjects (early-phase delay 24 s, venous-phase delay 75 s) and triphasic images in 29 (early-phase delay 24 s, venous-phase delay 60 s, delayed-phase delay 100 s). Retrospectively we assessed the number of nodules detected with each protocol in every phase, nodule conspicuity (graded I-IV) relative to surrounding parenchyma, and nodule patterns in the various phases. Nodule patterns were distinguished into homogeneous, peripheral, central and mixed hyperdensity, and homogeneous hypodensity. RESULTS: Thirty-seven lesions were found in the patients examined with the biphasic technique: baseline images showed 35% of the nodules, arterial images 92%, portal images 76% and combined arterial and portal acquisitions 95%. Sixty-one lesions were found in the patients examined with the triphasic technique: baseline images showed 43% of the nodules, arterial images 93%, portal images 70%, and delayed images 77%; combined arterial and portal acquisitions detected 93% of the nodules, combined arterial and delayed images 95%, combined arterial and delayed images 80%. Finally, 95% of lesions were demonstrated when the three phases were combined. Overall conspicuity grades were I in 44% of cases, II in 28%, III in 18% and IV in 10% of cases at baseline scanning; I in 9%, II in 24%, III in 34% and IV in 33% in the arterial phase; I in 28%, II in 41%, III in 18% and IV in 13% in the portal phase; I in 23%, II in 30%, III in 26% and IV in 21% of cases in the delayed phase. At baseline, 10% of lesions were hyperdense (homogeneously and peripherally in 5% each); mixed density was seen in 8%, and hypodensity in 82%. In the arterial phase, 93% of lesions were hyperdense (homogeneously in 80%, peripherally in 10% and centrally in 3%); mixed density was seen in 5%, and hypodensity in 1%. In the portal phase, 4% of lesions were hyperdense (homogeneously in 1% and centrally in 3%); mixed density was seen in 11%, and hypodensity in 85%. In the delayed phase, the lesions appeared mixed in 11% of cases and hypodense in 89%. CONCLUSIONS: Spiral CT scanning of small HCCs requires dedicated and meticulous technique. Multipassage assessment is mandatory, with 2 or 3 dynamic acquisitions of the whole liver. No major difference in nodule detection was demonstrated between these two options and thus the choice rests with the radiologist's preference. Early CT images proved best for lesion detection, followed by delayed, venous, and baseline studies; lesion recognition depends largely on nodular diameter. The same applies to conspicuity, which however depends on tumor volume less. Lesion patterns are quite typical and constant in all phases and are independent of lesion diameter.
Abstract: PURPOSE: To report our personal experience with helical CT evaluation of hepatocellular carcinoma treated with various percutaneous interventional procedures. We assessed both nodular response and the spectrum of changes within normal parenchyma. MATERIAL AND METHODS: December 1996 to September 1998 we examined with helical CT 41 patients (73 nodules in all) with hepatocellular carcinoma treated with percutaneous ablation therapies: conventional ethanol injection in 18 subjects (31 nodules), one-shot ethanol injection in 3 (8 nodules), radiofrequency thermal ablation in 16 (25 nodules), and combined chemoembolization and ethanol injection in 4 (9 nodules). CT performed was 4-27 days after the last session, acquiring biphasic volumetric images in 14 patients and triphasic volumetric images in 27. A second treatment with subsequent CT study was performed for 28 lesions; 15 underwent 3 serial studies and 6 underwent 4 studies. RESULTS: Compared with pretreatment findings, the diameter was unchanged in 62% of the nodules and increased in 38%. Morphology was unchanged in 63% of the lesions while in 37% a mild deformation toward the needle path or a more regular and round shape was evident. Borders were unchanged in 37% of the cases and modified in 63%, appearing well-defined in 73% and ill-defined in 27%. The necrotic portion had a low attenuation with a nodule-to-parenchyma gradient more evident on delayed than on venous and finally arterial acquisitions; 8% of the lesions were not recognizable on unenhanced scans. Residual viable tissue was identified in 44% of the nodules and quantified as 100% in 1% of all lesions, > 75% in 3%, > 50% in 4%, > 25% in 12%, < 25% in 23%. It was located centrally in 6% of the cases, peripherally in 12%, and eccentrically in 81%, and the shape was crescent in 66% of the cases, oval in 19%, and different in 16%. During the arterial phase the residual tumor appeared hyperdense in 97% of the nodules and isodense in 3%, while during the portal phase it was hyperdense in 22%, isodense in 28% and hypodense in 50%, and during the delayed phase hypodense in 100%. For what concerns the uninvolved parenchyma, lobar atrophy was present in 4% of the nodules, segmental atrophy in 8%, and subsegmental in 16%; caval thrombosis was found in 1 patient, portal thrombosis in 4. Arterioportal fistulas were identified in 5% of the nodules and areas of transient inhomogeneous attenuation in several cases. Subsegmental biliary dilation was detected in 4% of the lesions. CONCLUSION: Multiple-phase helical CT allows optimal depiction of primitive liver nodules treated with percutaneous interventional procedures and has a central role in the assessment of tumor response. Accurate is also the evaluation of changes or complications involving the surrounding parenchyma. Regarding the ablation effect, two typical features can be identified: after total necrosis nodular volume is unchanged or increased, borders are well-defined, and density is low and homogeneous (especially in delayed phases), while after partial necrosis the diameter is not modified, margins are ill-defined, attenuation is less decreased, and peripheral tumor maintains high density in arterial phase and low density in delayed phases. As for the treatment procedure, we found that thermal ablation with radiofrequency and single-session ethanol injection cause more evident alterations within both nodule and hepatic parenchyma, while after multi-session ethanol injection changes are less dramatic and consequently more difficult to assess.
Abstract: PURPOSE: The diagnostic imaging findings in hepatic amebiasis and the capabilities of percutaneous drainage have already been described but some debate is open on both diagnosis and treatment. We report our experience with ultrasound (US) and Computed Tomography (CT) studies of the hepatic amebic abscess and its management. MATERIAL AND METHODS: During the last 4 years we examined 14 patients with liver abscess: 11 men and 2 women; 13 were Italian and 1 African (25-61 years old, mean 36). All subjects underwent US and contrast-enhanced CT (with a conventional scanner in 12 and a helical unit in 2). The first 4 cases were also submitted to US-guided diagnostic aspiration. Six patients were treated with percutaneous drainage under US guidance using an 8-10 F pig-tail catheter which was removed 4-18 days later (mean 6). RESULTS: The abscesses were always single and uniloculated, in most cases located peripherally in the right lobe. They were large (2-11 cm, mean 7) and had round, oval, or irregular shape in 9, 3, and 2 cases respectively. US generally showed the abscess as an inhomogeneously hypoechoic mass with ill-defined walls. CT demonstrated a homogeneously hypodense collection with a thick peripheral hypodense halo; after contrast agent administration wall attenuation was increased between the edematous halo and the cavity, and an incomplete idosense ring appeared. Biphasic helical acquisitions allowed demonstration of some difference between the two vascular phases and yielded other interesting findings. Drug treatment provided complete abscess resolution in 8 patients, though in 2 it was badly tolerated. In one case no improvement was found and the patient was submitted to percutaneous drainage, which was the treatment of choice in the remaining 5 patients. The treatment was successful in all cases, but 1 patient who discontinued the combined medical therapy developed a heterotopic lesion. CONCLUSION: US and CT findings, though variable and partially different from those previously reported, may be considered sufficient for diagnostic assessment, especially if in the proper clinical and biohumoral setting. Both drug treatment and percutaneous drainage (to be considered for selected cases) are effective in the treatment of this type of abscess.
Abstract: PURPOSE: We report our preliminary experience concerning Doppler studies with the intravenous injection of a galactose-based echo contrast agent (SHU 508 A) in hepatocellular carcinomas (HCCs) treated with transcatheter arterial chemoembolization. We correlated US findings with those of iodized-oil helical CT. MATERIAL AND METHODS: In 1997 we examined 18 patients with cirrhosis and HCC (31 nodules in all) submitted to hepatic oily chemoembolization 15-30 days earlier. The lesions were studied with color and power Doppler US before and after echo contrast agent infusion (300 mg/mL, injection/nodule, constant rate in 60-90 s) and with Lipiodol CT (0-7 days after US). In the retrospective analysis, special care was paid to Doppler signals from pulsatile intra- and perinodular flow and to the detection of new small vessels on enhanced images. The signal was graded as absent (0), weak (1), medium (2) and strong (3). The oily agent uptake on CT images was graded as absent (0), grade I (< 10%), II (< 50%), III (> 50%) and homogeneous (IV). All scores were given on a blind basis. RESULTS: Liver enhancement was found in all cases and always lasted long enough to allow the accurate depiction of parenchymal lesions (at least 8 minutes). Signal intensity could be evaluated in 27 of 31 HCCs (2 were too deeply seated and two were too affected by cardiac activity). We had the following scores: basal color Doppler: grade 0 = 15 lesions, grade 1 = 8 lesions, grade 2 = 4 lesions; contrast-enhanced color Doppler: grade 0 = 11 lesions, grade 1 = 7 lesions, grade 2 = 8 lesions, grade 3 = 1 lesion; basal power Doppler: grade 0 = 12 lesions, grade 1 = 8 lesions, grade 2 = 6 lesions, grade 3 = 1 lesion; contrast-enhanced power Doppler: grade 0 = 10 lesions, grade 1 = 7 lesions, grade 2 = 8 lesions, grade 3 = 2 lesions; Lipiodol-CT: grade 0 = 1 lesion, grade I = 1 lesion, grade II = 7 lesions, grade III = 8 lesions, grade IV = 10 lesions. The difference between color and power Doppler scores, both compared to each other and between basal and enhanced images, never exceeded one. CONCLUSIONS: Contrast-enhanced Doppler US is a simple and fast technique allowing strong, constant and long-lasting enhancement. Doppler US techniques permit the effective and realistic study of HCC nodules treated with chemoembolization and show a better correlation with Lipiodol CT than basal studies. Power Doppler is slightly more sensitive and accurate than color Doppler and shows a better correlation with Lipiodol CT.
Abstract: PURPOSE: To describe and discuss the thoracic CT features of hypovolemic shock. MATERIAL AND METHODS: From a group of 18 patients with signs of hypovolemia on contrast-enhanced abdominal CT, 11 were selected for our study as having also undergone a complete chest examination. Pulse rate, blood pressure, trauma score value, Glasgow coma scale value, surgical result, and final outcome were retrospectively evaluated. The CT features analyzed were: decreased cardiac volume, reduced caliber of the thoracic aorta, aortic branches and caval venous system, increased enhancement of the aorta, and increased enhancement of the pulmonary collapses/contusions. RESULTS: All 11 subjects presented severe injuries and hemodynamic instability; 7 were stable enough to undergo surgery; only 1 of the 11 survived. Two patients showed none of the features of thoracic hypovolemia. All the other patients presented at least two signs: reduced caliber of the thoracic aorta in 7 cases; decreased volume of the cardiac chambers and increased aortic enhancement in 6; decreased caliber of the aortic vessels in 4; decreased caliber of the caval veins in 3; and increased enhancement of the pulmonary collapses/contusions in 3. CONCLUSIONS: In patients with hypovolemia, CT may show several thoracic findings in addition to abdominal ones. Knowledge of these features is important for distinguishing them from traumatic injuries.
Abstract: Acute mesenteric insufficiency is a surgical emergency with a difficult methodological approach. Its high mortality is mainly due to delay in the correct diagnosis. In turn, this is due to the lack of specificity, specially in the early-middle phase, of the clinical presentation, laboratory data, and plain abdominal radiographic findings. In front of this uncertainty, some authors advocated an "aggressive" approach with early use of angiography (nevertheless at risk of a high rate of negative examinations), other remained on more wait-and-see or fatalist positions, and other evaluated the possible diagnostic impact of noninvasive methods alternative to angiography. With the purpose of a correct employment from the surgeon of the various diagnostic tools actually available, we illustrated in this review the possibilities and limitations of the methods proposed in the evaluation of bowel infarction: plain abdominal radiography, gastrointestinal tract contrast studies, angiography, sonography, computed tomography (CT), magnetic resonance imaging (MRI).
Abstract: PURPOSE: We report on our personal experience with the radiologic and CT demonstration of the traspyloric duodenal spread of gastric carcinoma, whose relative frequency and prognostic value are recent literature data. MATERIAL AND METHODS: In the last 4 years we submitted to double contrast studies of the upper gastrointestinal (GI) tract 49 gastric carcinoma patients with antrum involvement. Twenty-one cases were staged with CT performed with gastric water distension, pharmacological hypotonia and dynamic contrast agent perfusion. Finally, 41 patients underwent surgical treatment. RESULTS: Radiologic evidence of transpyloric gastric carcinoma spread was found in 6 cases; CT, performed in 5 of them, was always in agreement. Five of 6 positive cases had surgical confirmation while one lesion was unresectable. No radiologic or CT false negatives were found among the remaining 36 surgical patients. Barium studies showed irregular antral lumen narrowing, rigid, open and eccentric pyloric channel, duodenal bulb deformity and irregular thickening. CT demonstrated antrum infiltration along the two gastric curvatures and the tumor spread to the duodenal cap. CONCLUSION: Antral cancer transpyloric spread is more frequent than previously reported and its presence should not exclude a carcinomatous process. Double contrast barium studies are a valuable tool in the demonstration of this spread, showing good correlation with CT staging findings.
Abstract: PURPOSE: To report our personal experience with color Doppler ultrasound (US) in the study of the ureterovesical jet in patients with recent renal colic. MATERIAL AND METHODS: First, the jet was studied in 10 healthy subjects and then 42 consecutive patients with urinary colic were submitted to plain radiography, which was sometimes integrated with conventional renal tomography, and real time US to detect the stone and to study the urinary tract above. Then, color Doppler function studies were carried out with transverse scans at the trigone and with the scan plane rotated on the ureterovesical junction. Retrospectively, the jet frequency, velocity, duration, volume, direction and interval were analyzed. Finally, all patients were examined with excretory urography. RESULTS: The jet had an anteromedial direction and exceeded the midline in the controls, with a peak velocity of 20-30 cm/s, mean duration of 15 s, mean frequency of 4-5 min and interjet interval 2-150 s. The jet was abnormal in the obstruction side in all renal colic patients; it was slow, continuous, decreased in volume and intensity, and prolonged in 26 patients--20 of them had incomplete lumbo-iliac ureteral obstruction and 6 pyeloureteral junction stones. The jet was diverted from its orientation in 7 subjects with intramural stones. There was no jet in 9 patients and urography demonstrated complete urinary obstruction--4 at the pyeloureteral junction and 5 at the lumbo-iliac ureter. CONCLUSIONS: Color Doppler US of the ureteral jet is a valuable tool in urinary colics because it yields in real time more pieces of functional information than radiography and B-mode US and also demonstrates the grade of urinary obstruction.
Abstract: A case of acquired volvulus as a cause of late small bowel obstruction, in a patient who had undergone a colectomy with ileal pouch-anal anastomosis two years previously, is described. Computed Tomography (CT) accurately demonstrated signs of adhesive strangulating obstruction, detecting also a radial disposition of the loops around the mesenteric root and an abnormal position of the superior mesenteric artery and vein on the right side of the aorta. From a literature survey, there are no previous studies reporting the CT appearance of a small intestine volvulus developed as a complication of an ileal pouch-anal anastomosis.
Abstract: BACKGROUND: The diagnostic procedures proposed in the evaluation of sigmoidovesical fistulas complicating diverticulitis are various and their effectiveness is still not well established. METHODS: Personal experience is based on 14 cases of colovesical fistulas secondary to sigmoid diverticulitis. Several diagnostic tools were employed: plain abdominal film (10 cases), large bowel enema (12), urography (3), cystography (2), sonography (4), and CT (5). The semeiotics of these fistulas were distinguished in direct, indirect, secondary, and related to the underlying disease. RESULTS: The fistulous tract itself was recognized in 100% of the cases with sonography, in 75% with enema, in 60% with CT, in 33% with urography, and in none with cystography. Vesical gas was visible in 100% of the cases with sonography and CT, and in 40% with plain radiographs. Diffusion of contrast medium was present in 91% of the cases with enema, in 60% with CT, and in 33% with urography. Focal thickening and/or irregularity of the bladder wall was evident with cystography and urography in 67% of the cases, with CT in 60%, with sonography in 50%, with enema in 8%. Diverticulosis/diverticulitis was recognizable in 100% of the cases with CT, in 91% with enema, in 25% with sonography. A paravesical abscess was recognizable in 40% of the cases with CT, in 25% with sonography, in 8% with enema. CONCLUSIONS: The radiourological procedures, though of limited use in our series, have a poor effectiveness. Large bowel enema and, specially, CT confirm as the method with greatest accuracy in the evaluation of these fistulas. The sonographic examination, according to personal preliminary experiences, is a valuable diagnostic alternative. Sonography and CT allow analysis of the perivisceral structures and, if compared with barium enema, provide a larger number of information on diverticulitis, which is essentially an extraluminal disease, and its complications.
Abstract: A 20-year-old man with massive ileal enterolithiasis was investigated with plain radiography, ultrasound, computed tomography, barium follow through and double contrast barium enema. Ileocecal valve agenesis was found at surgery. The enteroliths were located in the distal ileum, which communicated with the large intestine via an ileotransverse fistula.
Abstract: PURPOSE: To describe the possible CT features of perforated colorectal tumors and to discuss the practical value of detecting this complication. MATERIAL AND METHODS: The CT examinations of 16 patients with perforated large bowel neoplasms were retrospectively reviewed. The most frequent locations were the sigmoid colon (6 cases), the cecum and ascending colon (4 cases) and the descending colon (4 cases). A correlation with barium enema findings was possible in 12 patients while in 14 subjects surgical confirmation was obtained. RESULTS: The colorectal neoplasm was depicted on CT scans in 94% of cases, as a mural thickening or a mass, and was usually in the advanced stage. Phlegmonous tissue was shown only in 19% of the cases, while an abscess was detected in 81%, more frequently appearing as a well-defined fluid-filled collection near the tumor. Large bowel enema was positive for perforated neoplasm only in 5 cases. CONCLUSION: CT demonstrates perforated colorectal tumors better than conventional methods, which is a relevant information for both surgery and prognosis. In the diagnostic phase CT is indicated when clinical and/or barium enema findings are atypical. In the staging phase, the detection of this complication represents a valuable information.
Abstract: Although US is the method of choice in the evaluation of scrotal abnormalities, the literature is extremely poor regarding sonographic demonstration of scrotal hernias, especially bladder-containing ones. We report three cases of inguinoscrotal vesical herniation in which US was employed, proving to be satisfactory. We highlight the practical value of US, since a preoperative identification of the hernial content can avoid surgical bladder injuries and modify operative management of the herniation.
Abstract: Angiomyolipoma is an uncommon lipomatous neoplasm of the liver, usually asymptomatic and identified incidentally. We describe the CT findings of a surgically confirmed case of spontaneously ruptured angiomyolipoma with evidence of internal hemorrhage and hemoperitoneum. The CT features were that of an exophitic, oval, well-defined mass with inhomogeneous attenuation values due to the presence of fat- and soft-tissue densities. A review of the literature identified 49 cases of hepatic angiomyolipoma. Few of these occurred in symptomatic patients and showed intratumoral hemorrhagic foci, but none had a clear rupture with external bleeding. To our knowledge, this is the first reported case with this complication.
Abstract: PURPOSE: To assess the prevalence, significance, and practical value of two recently described CT signs of instable aneurysm: the crescent sign (a curvilinear high-attenuating density within the thrombus) and the periluminal halo (a low-attenuating internal layer of the thrombus around the patent lumen). MATERIAL AND METHODS: Among the CT examination performed in the last 5 years, we retrospectively selected the nonruptured aneurysms with a diameter exceeding 4 cm (no. = 93, average diameter 5.1 cm, unenhanced images in 28 cases and enhanced in 84) and the ruptured aneurysms (no. = 16, average diameter 6.7 cm, unenhanced images in 9 cases and enhanced in 9). We studied the prevalence of the crescent and halo sign, their relationship with the aneurysm diameter, and the effect of contrast enhancement. RESULTS: The crescent sign was identified with a statistically significant prevalence in ruptured (37.5% of cases) over asymptomatic aneurysms (5.5%); the halo, instead, had the same frequency in the 2 groups (12.5% and 9.5%, respectively). Both signs were more frequent in bigger aneurysms and were recognizable without differences in unenhanced and enhanced images. CONCLUSIONS: The crescent sign, though not exclusive of aneurysmal rupture, indicates instability and its detection should lead to careful follow-up or surgical repair. The halo seems to have no real value as risk factor.
Abstract: Intraosseous pneumatocyst of the ilium is a rare lesion of uncertain origin. It predilects male subjects and may be associated or not with sacroiliac joint degenerative disease, intra-articular gas, sacral pneumatocyst, and communication with the articular space. To our knowledge, only 16 observations have been reported in the literature. We have evaluated with plain radiographs and CT two additional cases. Plain films frequently identify these lesions, but CT is the method of choice in demonstrating their air density and assessing the possible abnormalities of the surrounding bone and sacroiliac joints.
Abstract: The faeces sign is a recently described computed tomography (CT) feature of small-bowel obstruction and is seen as a mottled, faeces-like content within the lumen of the dilated loops above the level of the obstacle. To evaluate its prevalence, significance, and diagnostic value we retrospectively reviewed 94 consecutive cases of small-intestine obstruction studied with CT in the last 6 years. The faeces sign was recognizable in 7 cases (7.4%) and was localized within ileal loops in all these subjects. In 6 of the 7 cases there was a simple and progressive obstruction, while there was a sudden onset with intestinal strangulation in only 1. The faeces sign is due to the intraluminal stagnation of enteric material and is generally recognizable in subjects with subacute obstruction. In our experience it is relatively uncommon. Nevertheless, it seems to be rather specific and may be a valuable accessory feature in the CT study of small-bowel obstruction.
Abstract: OBJECTIVE: To describe the radiological features of duodenal injury during endoscopic retrograde sphincterotomy (ERS) with special reference to limited papillary trauma and minor perforation. METHODS: The radiological and clinical features of duodenal injuries out of 284 ERS performed in the last 4 years were evaluated retrospectively to document various patterns of trauma and correlation with clinical outcome. RESULTS: Duodenal injuries occurred in eight patients: mild papillary injuries in five subjects (intrapapillary extravasation of contrast medium in one, peri-Vaterian submucosal diffusion in four) and duodenal perforation in three (peri-choledochal diffusion in one, retroperitoneal leakage in two). CONCLUSION: The radiological findings in papillary and duodenal injuries are protean and knowledge of their variable appearance is important since their detection may have practical consequences.
Abstract: Transient non-obstructing intussusception is known to occur in adults. While the CT findings in small bowel intussusception have been described in detail, few reports concerning transient cases have been published. We evaluated five patients with non-obstructive jejuno-jejunal invagination. All CT studies showed a target pattern with an intraluminal soft tissue mass, an eccentric mesentery, and a slightly dilated intussuscipiens. Transient intussusception has typical CT features and should be distinguished from more severe forms requiring prompt surgical treatment.
Abstract: PURPOSE: To report our experience concerning the integrated diagnostic imaging of intestinal intramural hematoma, with special reference to the different patterns and to the accuracy of US examinations. MATERIAL AND METHODS: In the last 4 years we examined 7 patients with intraparietal hematoma, due to anticoagulant therapy, using real-time US. All the subjects presented with abdominal pain, sometimes associated with distention, tenderness, bleeding, hematocrit reduction, palpable mass or obstruction. The hematomas involved the duodenum in 2 cases, the jejunum in 4, and the descending colon in 1. US was performed in all patients, plain abdominal radiographs in 6, oral barium studies in 1, large bowel enema in 1, and computed tomography (CT) in 3. All patients were managed conservatively except the one with colonic location who was treated surgically. RESULTS: In all subjects, the US findings were characteristic and included clean and defined double- or multilayered thickening of the bowel wall (usually with a thick and hyperechoic inner layer and a thin and hypoechoic outer layer), undulated mucous membrane, narrowed lumen with corpuscolated fluid content and gas spots, decreased peristalsis with fixity of the images, fluid between the loops. Plain abdominal radiographs were relevant in 3 cases, showing focal intestinal distention, thickening of the intestinal wall and of the valvulae conniventes, bowel lumen narrowing and fixity of the findings. The findings were nonspecific/negative in the 2 subjects with duodenal involvement and demonstrated an intestinal obstruction in that with colonic location. Oral barium study did not provide, in the single patient examined with this tool, specific results, only causing time consumption and diagnosis delay. Barium enema was valuable in demonstrating the presence and level of the colonic obstruction due to the hematoma. Similarly to US, CT always demonstrated the intestinal changes, with a better panoramic detailing, but did not provide relevant additional information. CONCLUSION: US shows a rather characteristic spectrum of findings in the intramural intestinal hemorrhage. The US data, possibly confirming plain abdominal radiographic findings, are in most cases relevant for the correct diagnosis of intraparietal hematoma and conclusive for the diagnostic course.
Abstract: PURPOSE: To report on our experience concerning a recently described double-contrast finding of gastritis related to the use of non-steroidal antiinflammatory drugs (NSAIDs), namely, flattening of the greater antral curvature. MATERIAL AND METHOD: The radiographic examinations of 41 subjects studied for NSAIDs gastropathy or for different reasons but with recent abuse of NSAIDs, were reviewed. The radiographs of 100 consecutive patients without history of NSAIDs use and evaluated for different questions were used as controls. RESULTS: Flattening of the greater curvature was present in 5 subjects (12%) with a prolonged history of NSAIDs use and in none of the controls. In three cases it was a solitary finding whereas in two it was associated with antral erosions. CONCLUSION: In our series, antral flattening was less frequent than reported in literature. Nevertheless, it may be a useful sign of NSAIDs gastropathy and may be especially relevant when representing the only evidence of gastric lesions related to NSAIDs.
Abstract: Interposition of the colon between kidney and psoas muscle may represent a benign anatomical variant that can be recognized on Computed Tomography (CT) images. In our series including 428 abdominal CT examinations, the position of the bowel in the pararenal space was studied with respect to the kidney and the psoas muscle. To determine the colon position in the pararenal space, three CT scans, at the upper pole, midkidney and lower pole, for each side, were selected. The colonic interposition between the kidney and the psoas muscle was then correlated with patient's age, sex and amount of perinephric fat. The ascending colon was interposed between the kidney and the psoas muscle in 6/428 cases (1.4%), appearing more frequently in adult men. Of these 6 cases, CT showed decreased perinephric fat in three cases, normal in one and increased in two. No case of descending colonic interposition between the kidney and the psoas muscle was demonstrated. CT is a valuable tool to depict this anatomical variation, preventing misdiagnoses and complications arising from interventional procedures.
Abstract: The computed tomographic (CT) appearance of two cases of sigmoid colon volvulus is described. Both underwent plain abdominal radiographs, contrast enema, and CT. The findings of sigmoid volvulus at CT were characteristic, having a whirl pattern of the dilated sigmoid loop around mesocolon and vessels and a bird-beak aspect of the afferent and efferent segments. CT may be valuable in a case of unusual clinical or plain film presentation as an alternative to contrast enema.
Abstract: Several conditions may simulate the radiolucent appearances of pneumoretroperitoneum at plain film. These include gas shadows in locations other than the retroperitoneal space or fluid within the retroperitoneal compartments. Two cases of emphysema within the soft tissues of the back mimicking pneumoretroperitoneum on plain radiographs are described. One case was secondary to epidural anesthesia and another to trauma. In both, computed tomography (CT) led to the correct diagnosis. The possible pitfalls in the differential diagnosis of retroperitoneal gas are described with emphasis of the diagnostic role of CT.
Abstract: Plain radiography is the method of choice in suspected perforating pneumoperitoneum. Nevertheless, especially when air collections are small, the technique must be very accurate, with patient mobilization and long examination times, which may be unfeasible in acute abdomen patients. To overcome these limitations, such cross-sectional imaging methods as US and especially CT are increasingly used. Our series consisted of 38 patients with gastrointestinal tract perforation examined 1990-94; thirty-one of them had surgical confirmation. CT had high sensitivity, demonstrating the presence of free intraperitoneal gas in more patients than conventional radiography (92% vs. 74%). Pneumoperitoneum was depicted between liver surface and anterior abdominal wall in 30 cases, in the subhepatic region in 17, posterior to the abdominal wall at paraumbilical level in 14, between the mesenteric folds in 8, in the pelvis in 7 and in other locations in 11. Extraluminal fluid collections were apparent in 79% of cases and contrast agent collections in 73%. The three most common findings were: intraperitoneal gas, fluid effusion and extraluminal contrast agent leaks (61.5%), gas and effusion (29%) and gas only (16%). The origin of the perforation was demonstrated in 82% of cases and its cause in 37%. CT was particularly useful in the diagnosis of clinically occult, of early and of confined perforations. Small gas bubbles, mild fluid effusion or minimum contrast agent leaks near perforation site are valuable signs. In selected cases CT can play an integrative role, thus improving the diagnostic accuracy of plain films.
Abstract: We report a case of acquired small bowel volvulus as a cause of late obstruction after ileal J-pouch anal anastomosis. Computed tomography (CT) demonstrated signs of strangulated, adhesive obstruction with radial disposition of the loops around the mesenteric root and abnormal position of the superior mesenteric artery and vein on the right side of the aorta. These features were due to the surgical manipulation and tension of the mesentery and its vessels during ileoanal anastomosis.
Abstract: PURPOSE: To report our experience in the study of acute left-sided colonic diverticulitis and to investigate the semiology and the possible diagnostic role of Computed Tomography (CT). MATERIAL AND METHODS: In the last 5 years, we examined with CT 52 patients with acute sigmoid diverticulitis. The examinations were performed with contiguous slices from the diaphragm to the perineum. An iodized contrast agent was administered orally in 32 cases and intravenously in 38. The diagnostic parameters we considered were: diverticula, pericolonic inflammation, thickening, intraparietal tracts, fistulas, pelvic phlegmons or abscesses, extrapelvic abscess or peritonitis, perforation, colonic obstruction, giant diverticula. Moreover, the cases were classified according to the system proposed by Neff in 5 stages. RESULTS: In order of frequency, the CT findings included: pericolonic inflammatory infiltration (96% of the cases), parietal thickening (90.5%), diverticula (88.5%), pericolonic and intrapelvic abscessual collections (38.5% each), pericolonic phlegmon and colonic performation (11.5% each), extramural fistula (9.5%), stenosis with colonic obstruction (6%), intramural tract and extrapelvic abscess (4% each), giant diverticulum (2%). As for the severity of the inflammatory involvement, 15% of the cases were included in stage 0, 29% in I, 42.5% in II, 13.5% in III, and none in IV. CONCLUSIONS: CT is an accurate diagnostic tool in the analysis of acute diverticulitis. Its main limitations are relative to the detection of early phases and the differentiation from carcinoma. CT should be performed to examine selected patients, with complicated diverticulitis.
Abstract: A new sign of pneumoperitoneum was observed in a patient with perforation of the ascending colon. The presence of free air in the peritoneal cavity allowed identification of the transverse mesocolon and the root of the small bowel mesentery on plain abdominal radiographs obtained in the supine and in the prone position. This sign may be an aid in the diagnosis of pneumoperitoneum.
Abstract: PURPOSE: To assess the frequency, significance, and diagnostic role of a recently described CT sign of small bowel obstruction, the faces-like content of the enteric lumen (the small bowel feces sign). MATERIAL AND METHODS: 82 cases of small bowel obstruction, studied with CT in the last 5 years, were retrospectively reviewed to identify possible feces-like luminal content of the dilated loops above the obstruction. RESULTS: The feces sign was identified in 6 cases of small bowel obstruction (7.3%), always within ileal loops. In 5 of 6 cases there was a simple and progressive obstruction while in one there was a hyperacute onset with intestinal strangulation. CONCLUSION: In our experience this sign is relatively uncommon. It is due to the intraluminal pooling of enteric material and is generally present in subacute obstruction. The sign seems to be rather specific and may represent a useful accessory diagnostic element.
Abstract: PURPOSE: To assess the semiology, effectiveness and role of the modern diagnostic methods used to study diaphragmatic injuries. MATERIALS AND METHODS: We report our personal experience acquired in the last 4 years in 23 patients. Eighteen patients had blunt and 6 penetrating diaphragmatic trauma, 10 of them involving the right and 14 the left hemidiaphragm. Plain chest X-rays were performed in 19 cases, gastrointestinal (GI) barium studies in 2, US in 5 and CT in 21 cases. RESULTS: Plain chest films were normal in one case (5%), not specific in 6 (32%), suggestive in 7 (37%), and diagnostic in 5 (26%). Barium studies of the GI tract were diagnostic in both patients (100%). US was suggestive in one case (20%) and diagnostic in 4 (80%). CT was not specific in 4 cases (19%), suggestive in 8 (38%) and diagnostic in 9 (43%). CONCLUSIONS: Plain chest radiography remains the method of choice in the study of diaphragmatic injuries. US, in our still limited experience, seems to be the most accurate method in the direct demonstration of muscular traumas and should be performed more often in the study of diaphragmatic injuries. CT has poorer accuracy and, above all, shows only indirect signs, but it is fairly effective and plays a key role in the depiction of chest and abdominal traumas. Barium studies should be reserved, possibly, to the direct identification of digestive hernias, especially in the late phase.
Abstract: Adrenal myelolipomas are usually small and asymptomatic tumors discovered incidentally. In a small number of cases, acute pain may develop secondary to intratumoral and/or retroperitoneal bleeding. We observed a large, surgically and histologically confirmed, myelolipoma of the right adrenal gland with spontaneous internal and external hemorrhage. CT demonstrated heterogeneity of the mass, obliteration of the surrounding fat planes, and retroperitoneal blood dissection. A literature review produced only 5 reports of ruptured myelolipoma with external hemorrhage.
Abstract: Plain abdominal film is the method of choice in the assessment of intestinal obstruction. This technique exhibits some limitations and must be frequently correlated with other diagnostic tools. Of them, US has been recently reported to allow the morphofunctional study of intestinal loops with high accuracy. Nevertheless, the literature on the usefulness of US disregards a sign of great interest, i.e., extraluminal fluid between bowel loops. Our personal experience in 56 adult patients with surgically confirmed small bowel obstruction suggests that this findings, demonstrated by US in 43 patients (73%), identifies early intestinal wall damage with high sensitivity. US, depicting fluid between bowel loops, can distinguish the various stages of obstruction, with major consequences on clinical management. US and plain abdominal film findings allowed us to distinguish three stages of obstruction: simple obstruction (15/56 patients, 27%), uncompensated obstruction (26/56 patients, 46%), and complicated obstruction (15/56 patients, 27%). These three evolutive stages exhibit different severity and require different surgical approaches.
Abstract: Among the various causes of free abdominal gas, there should be included those following chest injuries. In these cases, pneumoperitoneum may develop as a consequence of different physio-pathologic mechanisms and can be associated with pneumothorax and/or pneumomediastinum and/or retropneumoperitoneum. Gas can reach the peritoneal cavity in both blunt and penetrating chest traumas, following normal or abnormal pathways, i.e., diaphragmatic interruptions in the former case and congenital defects or post-traumatic diaphragmatic injuries in the latter case. In this trial, the authors investigated the clinical and semiologic meaning of this finding, frequently disregarded in traumatologic literature, which was observed in 6 cases of chest injuries: 4 blunt and 2 penetrating traumas. In this condition, even though conventional radiology remains the method of choice, CT can be considered as an integrative technique of great panorama allowing small amounts of free abdominal gas and related thoracic and abdominal injuries to be demonstrated, especially in the patients in forced supine decubitus, in whom abdominal plain films can be difficult to perform.
Abstract: The diagnosis of acute appendicitis is generally based on clinical and laboratory findings. In 1/3 of the cases, acute appendicitis presents atypically and, consequently, the contribution of the radiologist becomes necessary. Conventional radiologic methods, i.e. plain abdominal film and barium enema, generally yield aspecific and indirect information. In contrast, the modern methods of cross-sectional imaging, i.e. sonography and Computed Tomography (CT), allow to identify, directly and accurately, the inflammation of appendix and periappendiceal tissues. We report our experience with 25 cases of surgically confirmed adult acute appendicitis studied with abdominal CT examination. CT was usually performed with contiguous 5-mm-thick scans and with oral and intravenous contrast agent administration. CT showed abnormal appendix (72% of cases), pericecal or periappendiceal inflammatory infiltration (68%), phlegmon (20%), appendicoliths (16%), abscess (12%). CT was diagnostic for appendicitis in 21 cases (84%) and suggestive of it in 4 cases (16%). CT is an interesting diagnostic alternative to US in the assessment of clinically questionable cases of appendicitis. Furthermore, it is the method of choice in the analysis of complicated appendicitis and in the percutaneous management of periappendiceal abscesses.
Abstract: Intestinal ischemia is an uncommon disorder, whose incidence is nevertheless increasing and whose mortality remains high. The major cause of its poor prognosis is represented by the diagnostic delay depending on the poor specificity and late onset of the various clinical, biohumoral and radiographic signs associated with bowel infarction. On the one hand, the aspecificity of clinico-humoral findings and on the other hand its invasiveness prevent a broad use of angiography and call for the introduction of noninvasive methods. In our experience on 17 cases, Computed Tomography (CT), exhibiting sensitivity and specificity fairly higher than conventional radiology, makes a valid diagnostic tool in the examination of acute abdomen patients in general and in vascular emergencies in particular. With CT, diagnostic accuracy is fairly increased in acute mesenteric insufficiency. CT allows this condition to be detected earlier than conventional radiology and permits the early recognition, in a larger number of cases, of the patients who will benefit most from a surgical or radiologic treatment.
Abstract: In the last 3 years, the authors examined 564 patients with disturbed anorectal function. Of 41 incontinent subject in this series, 30 were retrospectively analyzed to assess the diagnostic contribution of double contrast barium enema, defecography and endoanal sonography. The authors propose a classification of fecal incontinence based on imaging findings: indeed, rectal incontinence can be distinguished from pelvic and sphincteral incontinence. Large bowel enema and defecography are the examinations of choice if rectal incontinence is suspected on the basis of clinical history and possible endoscopic, manometric and electromyographic findings. Defecography is suggested if pelvic incontinence is suspected, while anal endosonography is the exam of choice in case of suspected sphincteral incontinence. Especially thanks to the recent availability of the latter technique, today radiologists can directly visualize the anal sphincteral apparatus and its lesions, yielding objective evidence of this type of incontinence too. The authors report on both limitations and indications of each diagnostic method and conclude by stressing the fundamental role diagnostic imaging plays today in the study of this disorder.
Abstract: PURPOSE. To report the clinical and defecographic features of posterior rectal wall outpouchings, i.e., posterior rectocele and ischiorectal hernia. MATERIALS AND METHODS. Sixty-six patients with posterior rectal wall outpouching (61 with posterior rectocele and 5 with ischiorectal hernia) were selected among the patients examined in the last two years for defecation disturbance. All patients underwent physical examination, rectoscopy and videodefecography. RESULTS. Posterior rectal wall outpouchings were detected at physical examination in 28 patients and at rectoscopy in 9 patients. Posterior rectocele, more frequent and bigger in men, was usually demonstrated at videodefecography as an outpouching of the lower portion of posterior rectal wall: this finding was visible only in the dynamic phases in 51 patients while it was seen also at rest in 10 patients. In 52 patients, posterior rectocele was associated with other abnormalities--i.e., anterior rectocele (64%), puborectal muscle syndrome (38%), descending perineum (33%), mucosal prolapse (33%) and intussusception (20%). An ischiorectal hernia, defined as a posterolateral ampullar outpouching deeper than 4 cm and already visible at rest, was identified in 5 patients. Descending perineum and anterior rectocele were the most common associated disorders. CONCLUSIONS. We report the clinical and defecographic features of these rectal abnormalities and stress the importance of videodefecography in the real-time study of these morphofunctional disorders.
Abstract: High-resolution CT (HRCT) is a useful technique to investigate minimal diffuse lung disease. Two major limitations of HRCT are the higher radiation dose to the patient than in conventional CT of the chest and therefore the impossibility to study the lungs completely. These limitations can be partially overcome by using a low-dose protocol with mAs reduction. In our preliminary experience on 19 patients affected with various lung diseases, the low-dose protocol exhibited poorer image quality but almost equivalent anatomical detailing; the diagnostic yield was higher than that of conventional HRCT. Thus, in our experience, low-dose HRCT makes an interesting compromise in the study of lung parenchyma.
Abstract: Videoproctography has proved to be a useful diagnostic technique to investigate anorectal disorders; it can provide morphological and functional information which no other diagnostic method yields. From a series of 898 videoproctographs, the findings of 117 patients with rectal intussusception were retrospectively reviewed. The most common symptoms were an incomplete emptying feeling (93% of cases), obstructed defecation (78%), and a feeling of upright rectal weighting (71%). Of the three known types of rectal intussusception, the most common type was distal intussusception (44%), followed by the rectoanal type (38%) and finally by the proximal type (19%). The three types of intussusception were frequently (42%) associated with other disorders of rectal ampulla and especially with rectocele (15%), mucosal prolapse (8%), and descending perineum syndrome (12%); they had different clinical correlations and proctographic patterns and could be recognized in different defecation phases. In our personal experience, proctography with videorecording was a useful diagnostic tool in the dynamic assessment of this morphofunctional disorder which represents one of its major indications.
Abstract: Pneumoperitoneum secondary to gastrointestinal tract perforation is usually detected with plain abdominal films. Even when the examination cannot be performed in the upright position, free abdominal gas can be demonstrated with the accurate evaluation of supine radiographs. Some literature studies showed the value of ultrasonography and its higher diagnostic yield than that of plain abdominal films. However, in our experience on a series of 37 patients with surgically confirmed post-perforative pneumoperitoneum who underwent US first and radiography second, US had lower sensitivity than radiography (76% vs 92%, respectively). This was only partially compensated for by the detection of other signs and by better etiologic orientation. Therefore, we believe plain abdominal films to be still the method of choice to study the patients with suspected gastrointestinal perforation. Thus, US should be used in selected cases only--i.e., clinical conditions preventing radiographs from being performed correctly, persisting clinical suspicion with negative or questionable radiographic findings, the exclusion of other acute abdominal conditions, and finally the presence of pneumoperitoneum in the patients referred for different clinical reasons.
Abstract: We retrospectively analyzed our latest 564 defecographies to evaluate: the frequency of each single defecographic finding on the total number of patients and in the two sexes; the frequency of the finding as single disorder and in association with other anorectal disorders; the correlation between findings and symptoms. The most common disorders were anterior rectocele (54%), mucosal prolapse (53%), puborectalis muscle syndrome (15%), and intussusception (15%); this order is respected in women (70, 57, 17 and 16% of the study population) but differs in men (mucosal prolapse 42%, puborectalis muscle syndrome 18%, posterior rectocele 14%, and intussusception 14%). Intussusception and puborectalis muscle syndrome were identified as an isolated finding in many cases (55% and 43%, respectively). The most common associations are: posterior rectocele with anterior rectocele (58% of cases), anterior rectocele with mucosal prolapse and vice versa (63% and 64%), intussusception with anterior rectocele (52%), puborectalis muscle syndrome with mucosal prolapse (36%) and with anterior rectocele (49%) and descending perineum syndrome with anterior rectocele (81%) and with mucosal prolapse (70%). The low rate of association among some disorders should be mentioned too for example, mucosal prolapse is associated, with intussusception only in 10% of cases. Clinical-defecographic correlations are less apparent: if some symptoms are found to be more typical of some disorders, this correlation is not pathognomonic and the clinical picture is quite aspecific. We stress the value of a careful correlation between clinical-anamnestic and defecographic findings for the correct evaluation of these disorders.
Abstract: In 28 patients with systemic sclerosis interstitial lung involvement was investigated with high-resolution Computed Tomography (HRCT) in comparison with other diagnostic methods (respiratory function tests, lung scintigraphy and conventional radiography of the chest). The most frequent CT signs were: interlobular septal thickening, intralobular interstitial thickening, and ground-glass density. Their distribution was generally basal and posterior and high correlation was observed between the extent of lung disease and the cutaneous pattern of scleroderma. Pathological findings were present in 93% of cases: HRCT can must be considered more effective than the other methods in the evaluation of systemic sclerosis and should therefore be a fundamental diagnostic tool in the study and follow-up of interstitial diseases in the patients with systemic sclerosis.
