Abstract: PURPOSE: This study was undertaken to evaluate the role of the videofluorographic (VFG) swallow study in patients with systemic sclerosis. MATERIALS AND METHODS: Over a 23-month period, 45 women (mean age 58 years, range 27-76 years) with a known diagnosis of systemic sclerosis and a history of dysphagia underwent a dynamic and morphological study of the oral, pharyngeal and oesophageal phases of swallowing with videofluorography. All examinations were performed with a remote-controlled digital C-arm device with 16-in image intensifier, 0.6- to 1.2-mm focal spot range and maximum tube voltage of 150 kVp in fluorography and 120 kVp in fluoroscopy. Cineradiographic sequences were acquired for the swallow study with 12 images per second and matrix 512x512 after the ingestion of boluses of high-density (250% weight/volume) barium. The evaluation of oesophageal peristalsis was documented with digital cineradiographic sequences with six images per second in the upright and supine positions during the swallowing of barium (60% weight/volume), and the water siphon test was performed with the patient in the supine position to evaluate the presence of gastro-oesophageal reflux disease (GORD). All patients subsequently underwent laryngoscopy, endoscopy and pH monitoring, and the data thus obtained were processed and compared. RESULTS: The VFG swallow study identified alterations of epiglottal tilting associated with intraswallowing laryngeal penetration in 26 patients (57.8%), pooling of contrast agent in the valleculae and pyriform sinuses in 23 (51.1%) and radiographic signs of nonspecific hypertrophy of the lingual and/or palatine tonsils in 18 (40%). The study of the oesophageal phase revealed the presence of altered peristalsis in all patients, and in particular, 36 patients (80%) showed signs of atony. Altered oesophageal clearing mechanisms were evident in all 45 patients, sliding hiatus hernia in 43 (93%) and GORD in 44 (97%). CONCLUSIONS: Our study demonstrated that in patients with systemic sclerosis, there is no primary alteration of the oral or pharyngeal phase of swallowing. In addition, alterations of epiglottal tilting associated with laryngeal penetration of contrast agent were found to be secondary to chronic GORD. Indeed, in 40% of patients, radiographic signs were found that indicated nonspecific hypertrophy of the lingual tonsil and/or palatine tonsils and nonspecific signs of chronic pharyngeal inflammation, and GORD was identified in 93% of patients, which in 40% of cases extended to the proximal third of the oesophagus. The data obtained were confirmed in 85% of cases with pH monitoring and in all cases with laryngoscopy.

Abstract: In recent years, new technologies have become available for imaging small animals. The use of animal models in basic and preclinical sciences, for example, offers the possibility of testing diagnostic markers and drugs, which is becoming crucial in the success and timeliness of research and is allowing a more efficient approach in defining study objectives and providing many advantages for both clinical research and the pharmaceutical industry. The use of these instruments offers data that are more predictive of the distribution and efficacy of a compound. The mouse, in particular, has become a key animal model system for studying human disease. It offers the possibility of manipulating its genome and producing accurate models for many human disorders, thus resulting in significant progress in understanding pathologenic mechanisms. In neurobiology, the possibility of simulating neurodegenerative diseases has enabled the development and validation of new treatment strategies based on gene therapy or cell grafting. Noninvasive imaging in small living animal models has gained increasing importance in preclinical research, itself becoming an independent specialty. The aim of this article is to review the characteristics of these systems and illustrate their main applications.

Abstract: Cardiac iathrogenic lesions can occur during diagnostic or therapeutic procedures. Resistance of the heart to an injury may cause a delay from the traumatic event to onset of the symptomatology or to heart rupture. We describe a rare case cardiac perforation with delayed rupture of the heart in a patient previously submitted to radiation therapy for breast cancer. Cardiocutaneous fistula at the cross-sectional computed tomographic and magnetic resonance imaging findings has not been previously reported, to our knowledge.

Abstract: PURPOSE: Dysphagia is a symptom of different pathological conditions characterised by alteration of the swallowing mechanism, which may manifest at different levels. We report our experience in the evaluation of the swallowing mechanism with combined videofluoroscopy and manometric recordings. MATERIALS AND METHODS: For the combined study, we used a Dyno Compact computerised system (Menfis Biomedical s.r.l., Bologna, Italy) equipped with: (1) graphics card for the management of ultrasonographic or radiological images; (2) A.VI.U.S. dedicated software package, which enables digital-quality recording (PAL/NTSC, composite video or S-Video) of the videofluoroscopy study in AVI format with 320 x 240 resolution and 25 Hz acquisition frequency. The delay introduced by the process of image digitalisation is in the order of 200 ms, so for analysis purposes, the images can be considered synchronised with the manometric recordings. The videomanometry study was performed with the administration of contrast material either in bolus form or diluted. Data were collected on a specifically designed grid for the evaluation of 46 videofluoroscopic items, of which 34 are derived from the laterolateral view (seven in the oral preparatory phase, 15 in the oral transport phase and 12 in the pharyngeal phase) and 12 in the anteroposterior view (six in the oral preparatory phase and six in the oropharyngeal phase). A positive finding for the individual parameters is expressed in a binary fashion. Manometric evaluation was based on 11 items divided into four major and seven minor criteria. RESULTS: Dynamic videofluoroscopy swallow study combined with concurrent manometry enabled the simultaneous recording of anatomical alterations and the functional data of oropharyngeal pressure, thus providing a picture of the anatomical, biomechanical and physiological conditions of swallowing and the manner of bolus propulsion and transit. CONCLUSIONS: An early and effective diagnosis of oropharyngeal dysphagia means being able to effectively implement appropriate rehabilitation techniques, improve the patient's quality of life, and minimise the complications associated with swallowing disorders (choking, aspiration pneumonia, malnourishment). Distinction of the anatomical level of dysphagia is not a matter of simple classification; rather, it is essential in that different clinical presentations require different diagnostic strategies, and a precise definition of the anatomical-functional substrate is required to implement the correct therapeutic approach. This study presents the authors' experience with the use of combined videofluoroscopy and manometry with particular emphasis on the examination technique.

Abstract: PURPOSE: The aim of this study was to demonstrate the possibility of rectal diverticula developing in patients treated with endoanal circular staplers for haemorrhoids (Longo's stapled haemorrhoidectomy) or obstructed defaecation syndrome [stapled transanal rectal resection (STARR)]. MATERIALS AND METHODS: Between January 2005 and December 2006, we carried out 634 defaecographic examinations. Of these, 45 were postoperative follow-up studies of patients who had been treated with the Longo technique (n = 13) or STARR technique (n = 32). RESULTS: Seven out of 45 patients, five of whom were women treated with the Longo technique and two men with the STARR technique, developed rectal diverticula. One diverticulum was located on the left lateral rectal wall, four on the posterior wall and two on the anterior wall. All diverticula had arisen from the surgical suture point. In one case, the diverticulum was discovered incidentally during a double-contrast barium enema. One of the male patients, who had been treated with the Longo procedure 5 years earlier, developed acute pain due to faecal stasis in a widenecked diverticulum abutting the posterior rectal wall. CONCLUSIONS: The use of endorectal stapling devices can lead to focal weakness at the point of surgical suture on the rectal wall and predispose to the development of rectal diverticula.

Abstract: PURPOSE: E-learning, an abbreviation of electronic learning, indicates the provision of education and training on the Internet or the World Wide Web. The impact of networks and the Internet on radiology is undoubtedly important, as it is for medicine as a whole. The Internet offers numerous advantages compared with other mass media: it provides access to a large amount of information previously known only to individual specialists; it is flexible, permitting the use of images or video; and it allows linking to Web sites on a specific subject, thus contributing to further expand knowledge. Our purpose is to illustrate the regulatory aspects (including Internet copyright laws), current radiological applications and future prospects of e-learning. Our experience with the installation of an e-learning platform is also presented. MATERIALS AND METHODS: We performed a PubMed search on the published literature (without time limits) dealing with e-learning tools and applications in the health sector with specific reference to radiology. The search included all study types in the English language with the following key words: e-learning, education, teaching, online exam, radiology and radiologists. The Fiaso study was referred to for the regulatory aspects of e-learning. RESULTS: The application of e-learning to radiology requires the development of a model that involves selecting and creating e-learning platforms, creating and technologically adapting multimedia teaching modules, creating and managing a unified catalogue of teaching modules, planning training actions, defining training pathways and Continuing Education in Medicine (CME) credits, identifying levels of teaching and technological complexity of support tools, sharing an organisational and methodological model, training the trainers, operators' participation and relational devices, providing training, monitoring progress of the activities, and measuring the effectiveness of training. Since 2004, a platform--LiveLearning--has been used at our university: this is a Web-oriented application, that is, an Internet software solution that users can access through a Web browser. The pages displayed by the browser are dynamically generated through interaction with a database that collects both data required for the application to work and data related to the courses provided. There are different approaches to developing applications that use databases to store information. The selected approach is based on a modular three-level architecture divided into presentation level, intermediate level, and data level. The LiveLearning platform includes modules to manage multimedia contents and to interface with the streaming server so that the student can access the training contents directly from the platform interfaces. Furthermore, the platform offers its users different modules: Teaching Units, Documents, Forums, and Chats. By appropriately combining these modules, customised training can be devised based on specific requirements. CONCLUSIONS: The increasing diffusion of continuous education will reduce the costs of e-learning and make this training method, which helps keep pace with technological progress, more attractive, with significant professional gains for radiologists.

Abstract: In these three words--genomics, proteomics and nanotechnologies--is the future of medicine of the third millennium, which will be characterised by more careful attention to disease prevention, diagnosis and treatment. Molecular imaging appears to satisfy this requirement. It is emerging as a new science that brings together molecular biology and in vivo imaging and represents the key for the application of personalized medicine. Micro-PET (positron emission tomography), micro-SPECT (single photon emission computed tomography), micro-CT (computed tomography), micro-MR (magnetic resonance), micro-US (ultrasound) and optical imaging are all molecular imaging techniques, several of which are applied only in preclinical settings on animal models. Others, however, are applied routinely in both clinical and preclinical setting. Research on small animals allows investigation of the genesis and development of diseases, as well as drug efficacy and the development of personalized therapies, through the study of biological processes that precede the expression of common symptoms of a pathology. Advances in molecular imaging were made possible only by collaboration among scientists in the fields of radiology, chemistry, molecular and cell biology, physics, mathematics, pharmacology, gene therapy and oncology. Although until now researchers have traditionally limited their interactions, it is only by increasing these connections that the current gaps in terminology, methods and approaches that inhibit scientific progress can be eliminated.

Abstract: Gastrointestinal disorders are common in elderly patients, and the clinical presentation, complications, and management may differ from those in younger patient. Most impairment occurs in the proximal and distal tract of the gastrointestinal system. Swallowing abnormalities with a wide span of symptoms and pelvic floor pathologies involving all the pelvic compartments are common. Acute abdomen, often from small bowel obstruction or mesenteric ischemia, can pose a diagnostic challenge, because a mild clinical presentation may hide serious visceral involvement. In this setting, the radiologist often is asked to suggest the appropriate management options and to guide the management.

Abstract: PURPOSE: Chronic coccygodynia is a difficult problem diagnostically and therapeutically. Moreover, there is no deep knowledge especially in the field of imaging of chronic coccygodynia. In this study several possible measurements are proposed, which all are able to demonstrate coccygeal movement during defecation, in order to assess coccygeal mobility using dynamic MRI during maximum contraction and during straining-evacuation. MATERIALS AND METHODS: A dynamic MRI study of the pelvic floor was performed in 112 patients. Five methods of measurement were assessed. Coccygeal movements were determined through the evaluation of three angles pair and two different distances measured during the phase of maximum contraction and during the phase of straining-evacuation. Results were compared according to age, sex, parity and experience of minor trauma. No patient included in the study had coccygodynia. Measurements taken by two radiologist were compared to determine interobserver agreement. RESULTS: The maximum measurement values of the two distances are homogeneous, between 9 and 9.4mm. The maximum measurement values of the three angles showed a difference that is between 21 degrees and 38 degrees . Two of three angles showed a major measurement values in the funtional texts. In only one patient the coccyx was not mobile. CONCLUSION: Our dynamic MRI study indicates that the coccyx is mobile during defecation and that it is possible to demonstrate coccygeal excursions by assessing the difference between its positions at maximum contraction and during straining-evacuation. The measurement methods used in this study for evaluating coccygeal movements resulted in variably sized observed differences, but all yielded statistically significant results in demonstrating coccygeal excursion. Among the five measurement methods, two resulted in the largest differences. Our data indicate no correlation between coccygeal movements and age, sex, parity, minor trauma and coccygodynia.

Abstract: OBJECTIVE: MDCT is performed as first imaging examination for patients with acute abdomen in most Emergency Departments. Clinical suspicion of ischemic colitis and infarction is related to specific findings, however, differential diagnosis as well as the staging for a confirmed ischemic affection may be critical. The individual signs from ischemia to infarction of large bowel is a captivating topic. In this study, we report our experience of the MDCT assessment of acute colonic disease from vascular mesenteric disorders. MATERIALS AND METHODS: We retrospectively reviewed the MDCT findings of 71 patients admitted to our attention for acute abdomen, with final proven diagnosis of colonic ischemia and/or infarction made by surgery and/or endoscopy. CT-scanning of the abdomen and pelvis was performed after i.v. contrast medium administration, using a multidetector row CT equipment. We correlated the presence of parietal disease, the evidence of mesenteric arterial or venous vessels occlusion, the parietal features as well as others findings, such as free fluid and/or air in peritoneal recess or in retroperitoneum, with the surgical and/or endoscopic findings. RESULTS: Analysis of our data showed a segmental (84%) or complete (16%) involvement of the colon; 57 cases were related to ischemia, 14 to infarction. Inferior mesenteric vessels defect of opacification was noted in 10 cases. Various degree of wall thickening and parietal enhancement, peritoneal fluid, mural or portal-mesenteric pneumatosis were compared to evidence of mesenteric arterial or vein occlusion and to final proven diagnosis. A classification in a multi-stage grading for both decreased of arterial supply or impaired venous drainage disorders was done. CONCLUSIONS: A grading scale from ischemia to infarction affecting the large bowel from arterial or venous mesenteric vessels origin has been not previously reported in a series at our knowledge. MDCT findings may support the clinical evaluation of patients affected by acute colon from vascular disorders. In particular, it seems to provide effective and valuable information's in differentiating etiology and stage of disease.

Abstract: OBJECTIVE: To report the prevalence and to describe the atypical centrifugal (inside-out) appearance of contrast-enhancement of liver hemangiomas on contrast-enhanced sonography. MATERIALS AND METHODS: Baseline and SonoVue-enhanced ultrasonography of 92 patients with 158 liver hemangiomas - considered atypical at grey-scale examination and confirmed by computed tomography, magnetic resonance imaging and ultrasound follow-up - were reviewed in consensus by two experienced radiologists, who evaluated baseline echogenicity and the dynamic enhancement pattern of each lesion looking for the presence of central enhancing foci in the arterial phase followed by a centrifugal (inside-out) enhancement in the portal-venous and late phases. RESULTS: After administration of SonoVue, 12/158 hemangiomas (7.6%) (size range: 1-7cm; mean: 3.2cm) in seven patients (5 women, 2 men; age range: 34-71 years, mean: 50.8 years) showed a central enhancing focus in the arterial phase followed by a centrifugal enhancement in the portal-venous and late phases. In all cases centrifugal enhancement was incomplete at contrast-enhanced sonography, whereas computed tomography and/or magnetic resonance imaging were able to depict a complete and homogeneous fill-in. CONCLUSION: Radiologist should be aware that centrifugal (inside-out) appearance on contrast-enhanced sonography is a rare but possible feature of liver hemangioma.

Abstract: This paper examines the diagnostic potential of multislice computed tomography enteroclysis (MSCT-E) to detect and assess different diseases affecting the small bowel, emphasising the increasingly important role assumed by the technique in the study of this anatomical region. After a short summary of the technical aspects, we discuss the different findings that can be observed during an MSCT-E study and that enable detection of small-bowel disease and, if necessary, assessment of the extent and stage of disease.

Abstract: Mermaid or sirens have been part of the cultural tradition of the sailors during the first expeditions in the western world. The Siren's Myth appeared for a first time with Homer, who described in the Odyssey some singing creatures that lured the enchanted sailors to death. More frequently described with a bird body and a female head, sometimes the female part was extended to torso, with arms prolonged in sturdy claws. In the Latin literature Publius Ovidius Naso presented in the Métamorphoses these creatures. Proposed ethymology for the word "siren" seems to confirm the prerogatives of these creatures, related to magnetism, seduction, charm. The first figuration of Sirens resembling to fish-women was in the second century bc. Hans Christian Andersen provided to leave us the strongest legend of Siren in the well-known fairy tale "The Little Mermaid". Following this story, Sirens are definitely considered as beautiful half-fish women who lived in the bottom of the sea, having a lovely voice to be used when they rise up to allow sweeter the agony of the wrecked sailors. Beyond the Myth, may the Siren really exist? It can be hypothesized that these creatures probably were individuals affected by sirenomelia. In our literature and medical review, we describe the etiology of the disease, and we illustrated the anatomical features of fetuses affected by this pathology using MDCT 3D reconstructions. Syrenomelia is a condition not compatible with the normal life, however nine cases of "mermaid" survived to reconstructive surgery have been reported until now. In our report we also presented a case of survival baby girl affected by sirenomelia, before and after surgery, with correlative radiologic imaging findings. The most important characteristic that seems to allow survival of the affected individuals is the presence of one functional kidney, displaced in pelvis. As so dramatically tragic was the history of the Andersen Little Mermaid, so unattended pleasant would be the destiny of a modern mermaid, who can hope to finally marry her prince, without the risk to "loose her head", as the Copenhagen City's Symbol did in the past years, for a story beyond the Myth.

Abstract:

Abstract: PURPOSE.: The purpose of this study was to determine the role of plain chest radiography in the evaluation of patients with suspected foreign-body aspiration. MATERIALS AND METHODS.: During a 5-year period, 31 patients (18 men and 13 women; age range 6 months to 85 years) were referred to our observation for clinical suspicion of foreign-body aspiration. Clinically, the patients presented with cough in 27/31 cases (87.1%), decreased breath sounds in 22/31 (71%), choking in 18/31 (58.1%), fever in 7/31 (22.6%) and cyanosis in 5/31 (16.1%). Suspected foreign-body aspiration had occurred 2-72 h before hospitalisation. Within 2 h of hospitalisation, all patients underwent plain chest radiography performed in the upright position (two projections) in 10/31 (32.3%) patients and in the supine decubitus position in the remaining 21 (67.7%) patients. Plain chest radiography was subsequently integrated with multislice computed tomography (MSCT) of the chest in 3/31 (9.7%) patients and with bronchoscopy in 27/31 (87.1%) patients. RESULTS.: Plain chest radiography showed the presence of a foreign body in the tracheobronchial tree in 7/31 (22.6%) patients, who subsequently underwent successful bronchoscopy in all cases. Foreign bodies included tooth fragment (three cases), nail (two cases), metallic spiral of a ball-point pen (one case) and an earring (one case). In the remaining 24/31 patients, plain chest radiography was positive in 14 cases, showing atelectasis (seven cases), pneumonia (six cases), pulmonary hyperinflation (one case) and pneumomediastinum (one case). Such findings had been caused by an aspirated foreign body, which was subsequently removed by means of bronchoscopy in all 14 patients. Moreover, three of the remaining ten patients with negative plain chest radiograph were submitted to MSCT of the chest, which required in 1 case tracheobronchial aspiration of a foreign body that was subsequently removed by means of bronchoscopy. Overall, plain chest radiography showed the presence of foreign-body aspiration and/or pleuroparenchymal lesions in 21/31 patients (67.7%); bronchoscopy was positive in 23/27 patients (85.2%), localising the foreign body in the right main bronchus in 16/27 patients (59.3%), left main bronchus in 7/27 patients (25.9%), intermediate bronchus in 2/27 patients (7.4%) and right lower lobe bronchus in 2/27 patients (7.4%). No late complications were observed within 6 months of hospital discharge. CONCLUSIONS.: Plain chest radiography remains the initial imaging modality for patients with clinically suspected tracheobronchial aspiration of a foreign body. Nevertheless, in the case of negative chest radiography and a clinical suspicion of foreign-body aspiration, MSCT - possibly integrated with virtual bronchoscopy - should be considered in order to avoid unnecessary bronchoscopy.

Abstract: The authors illustrate the technique for small-bowel imaging using enteroclysis with multidetector-row computed tomography (MDCT), underscoring the important role played by CT in the assessment of the small bowel thanks to the advent of first the spiral and later the multidetector technique. The paper makes a detailed comparison of the various methods that have been used in CT study of the small bowel and proposes a standardised technique to achieve correct distension of bowel loops and adequate evaluation of bowel wall vascularity, making reference to the well-consolidated experiences of the various Italian research groups. The paper accurately describes the different procedures required for CT assessment of the small bowel, from nasojejunal intubation to the selection of the most appropriate acquisition phases for assessment of bowel wall vascularity.

Abstract: PURPOSE: The purpose of this study was to determine the role of plain chest radiography in the evaluation of patients with suspected foreign-body aspiration. MATERIALS AND METHODS: During a 5-year period, 31 patients (18 men and 13 women; age range 6 months to 85 years) were referred to our observation for clinical suspicion of foreign-body aspiration. Clinically, the patients presented with cough in 27/31 cases (87.1%), decreased breath sounds in 22/31 (71%), choking in 18/31 (58.1%), fever in 7/31 (22.6%) and cyanosis in 5/31 (16.1%). Suspected foreign-body aspiration had occurred 2-72 h before hospitalisation. Within 2 h of hospitalisation, all patients underwent plain chest radiography performed in the upright position (two projections) in 10/31 (32.3%) patients and in the supine decubitus position in the remaining 21 (67.7%) patients. Plain chest radiography was subsequently integrated with multislice computed tomography (MSCT) of the chest in 3/31 (9.7%) patients and with bronchoscopy in 27/31 (87.1%) patients. RESULTS: Plain chest radiography showed the presence of a foreign body in the tracheobronchial tree in 7/31 (22.6%) patients, who subsequently underwent successful bronchoscopy in all cases. Foreign bodies included tooth fragment (three cases), nail (two cases), metallic spiral of a ball-point pen (one case) and an earring (one case). In the remaining 24/31 patients, plain chest radiography was positive in 14 cases, showing atelectasis (seven cases), pneumonia (six cases), pulmonary hyperinflation (one case) and pneumomediastinum (one case). Such findings had been caused by an aspirated foreign body, which was subsequently removed by means of bronchoscopy in all 14 patients. Moreover, three of the remaining ten patients with negative plain chest radiograph were submitted to MSCT of the chest, which required in 1 case tracheobronchial aspiration of a foreign body that was subsequently removed by means of bronchoscopy. Overall, plain chest radiography showed the presence of foreign-body aspiration and/or pleuroparenchymal lesions in 21/31 patients (67.7%); bronchoscopy was positive in 23/27 patients (85.2%), localising the foreign body in the right main bronchus in 16/27 patients (59.3%), left main bronchus in 7/27 patients (25.9%), intermediate bronchus in 2/27 patients (7.4%) and right lower lobe bronchus in 2/27 patients (7.4%). No late complications were observed within 6 months of hospital discharge. CONCLUSIONS: Plain chest radiography remains the initial imaging modality for patients with clinically suspected tracheobronchial aspiration of a foreign body. Nevertheless, in the case of negative chest radiography and a clinical suspicion of foreign-body aspiration, MSCT-possibly integrated with virtual bronchoscopy-should be considered in order to avoid unnecessary bronchoscopy.

Abstract: OBJECTIVE: Gastric blunt traumatic injuries are uncommon and their radiological appearance has been infrequently reported in medical literature. These injuries are difficult to diagnose preoperatively, though they require immediate recognition to minimize their otherwise high mortality and morbidity. The aim of our study is to describe the radiological appearance of blunt gastric traumatic injuries. MATERIALS AND METHODS: Retrospective evaluation of a 25 patients series observed between January 1997 and May 2005. RESULTS: We observed rupture of the stomach in 20% of cases, in 44% of cases a partial lesion of the stomach, in one case a necrotic post-traumatic volvulus, five patients (20%) had benign portal pneumatosis, in three patients the stomach was secondarily involved because of a diaphragmatic hernia. The fundus resulted to be the most frequently damaged part of the stomach (80%). CONCLUSIONS: Blunt traumatic injuries need a careful and systematic approach given their economical and social relevance. For these reasons uncommon lesions require attention and may be important to search for specific findings of gastric lesions.

Abstract: Injuries to the small and large intestine from blunt trauma represent a defined clinical entity, often not easy to correctly diagnose in emergency but extremely important for the therapeutic assessment of patients. This article summarizes the MDCT spectrum of findings in intestinal blunt lesions, from functional disorders to hemorrhage and perforation.

Abstract: Diagnostic imaging is very important in the diagnosis and management of the emergency patient. It is necessary for the emergency radiology unit to be located within the Emergency Department, and to allow the interdisciplinary management of the patient by all specialists. Logistics, technological equipment and staff of the emergency radiology unit must be designed and worked out in the best way to guarantee the fastest and effective assistance to the emergency patient.

Abstract: Longo's procedure of double stapled trans anal rectal resection (STARR) has been evocated as surgical treatment of the obstructed defecation syndrome (ODS) in patients with rectal mucosal prolapse. The aim of this study was to investigate the post-interventional findings of this technique, to help radiologist in knowledge of the changed morphology of the rectal lumen, also in attempt to recognize some potential related complications.

Abstract: A wide range of surgical procedures are performed for either benign and malignant esophageal lesions, that may be classified as demolitive or conservative interventions. The former is characterized by resection and replacement of the esophagus with another organ, whereas conservative surgery is obtained preserving esophageal function without resection. Knowledge of surgical techniques and major complications is extremely important for a correctly performed radiographic study and a proper interpretation of the imaging findings. Functional evaluation of the operated alimentary tract and early detection of postoperative complications are essential for a successful recovery of esophageal surgery patients. We provide a brief overview of the main esophageal surgical procedures, reporting our experience on postoperative imaging of 104 patients submitted to surgery for either benign or malignant esophageal disease during a 6-year period.

Abstract: The aim of our study was to evaluate the reliability of MDCT-enteroclysis (MDCT-E), an emerging technique of small bowel examination that combines the advantages of MDCT examination of the abdomen and the enteral volume challenge of enteroclysis, in evaluation of small bowel neoplasms. In our institutions, MDCT-E was used to study 456 patients (age range 21-84 years, mean 53 years) admitted for suspicion of small bowel disease. All examinations were done on multichannel CT units, 129 on a 16-slice scanner and 327 on a four-slice scanner. Post-processing and multiplanar reformatting and interpretation were performed on dedicated workstations. After adequate gastrointestinal preparation and naso-enteric intubation, small bowel was distended by methylcellulose infused by a peristaltic pump. One volumetric MDCT acquisition was obtained after 120-130 ml of intravenous contrast medium. Multiplanar reformatting was based on the image reconstruction parameters from 3 to 4 mm. Forty-five small bowel neoplasms were found; in the remaining cases, 223 Crohn's diseases and 149 other abnormalities were detected. All findings were confirmed by surgery, endoscopy or clinical follow-up. In our experience, MDCT-E with neutral enteral and IV contrast seems to be a reliable method in the diagnosis of small bowel neoplasms.

Abstract: In this pictorial essay, we consider the post operative MDCT findings after liver resection, transplantation, surgical managed major trauma and radiofrequency ablation of focal lesions. Common complications such as fluid collections, hemorrhage, biloma, vascular disease, hematoma, abscesses will be also considered.

Abstract: PURPOSE: Ogilvie's syndrome is defined as an acute pseudo-obstruction of the colon, characterized by the signs, symptoms and radiological pattern of a large-bowel obstruction, but without a detectable organic cause. The aetiology of Ogilvie's syndrome appears to be multifactorial, with a series of possibly interacting pathogenic noxae all resulting in colon inactivity. Our study reports on six cases of Ogilvie's syndrome diagnosed and treated between 1997 and 2002. MATERIALS AND METHODS: From October 1997 to September 2002 we studied six patients affected by pseudo-obstruction of the colon. The pseudo-obstruction was recurrent in two cases. Acute dilatation of the colon without radiologically-detectable organic obstruction was the inclusion criterion for the study. RESULTS: Plain abdominal radiography revealed colon dilatation that extended to the splenic flexure in three patients, to the hepatic flexure in two patients, and confined to the transverse colon in one patient. None of the patients showed air-fluid levels of the small intestine. CONCLUSIONS: The most relevant clinical finding in Ogilvie's syndrome is abdominal distension, which arises suddenly, has a progressive course and reaches massive levels. The first-line diagnostic investigation is plain abdominal radiography which shows extreme colon dilation without air-fluid levels of the small intestine. In three of our patients, conservative therapy alone was able to restore normal conditions within five days; two patients required decompressive colonoscopy, and one patient died from cardio-circulatory arrest after 48 hours.

Abstract: OBJECTIVE: Small-bowel obstruction from gallstone impaction is a pathological entity frequently observed in elderly patients with a history of cholelithiasis or cholecystitis. Diagnostic imaging plays a great role in the management of patients with suspected gallstone ileus and overall in the correct predictive diagnosis: in the last years, some experiences in radiologic diagnosis of this entity by sonography, abdominal plain film and CT, and occasionally MRI have been reported. Some questions related to gallstone ileus are to be considered: one of them is the possibility of recurrence, which increases the operatory risk in these patients. Recurrence may be due either to the presence of overlooked stones that were already in the bowel at the time of surgery but not identified and not removed or to the migration of other stones in patients not previously cholcystectomized. In cases of acute abdomen, establishing an effective conservative therapy may be a critical point. The aim of this retrospective study was to evaluate the capabilities of helical single-detector and MDCT scanners to allow a correct diagnosis of this disease. CONCLUSION: Helical single-detector and MDCT may improve the diagnosis of gallstone ileus, providing important information regarding the exact number, size, and location of ectopic stones and the site of intestinal obstruction or direct visualization of a biliary-enteric fistula, to help clinicians in the therapeutic management of patients.

Abstract: OBJECTIVE: Our study was focused on the evaluation of fluid dynamics to assess the value of gray-scale and color Doppler sonography for evaluating the development of fetal swallow-related movements from early gestation until birth. MATERIALS AND METHODS: We examined 56 fetuses from weeks 15-39 of gestation. Each fetus was examined throughout four distinct periods of gestation: weeks 15-18, 22-25, 30-34, and 37-39. During the examination, seven gray-scale sonography or color Doppler sonography patterns and their prevalence were considered. RESULTS: Mandibular and/or labial movements (chi2 = 56.4, p < 0.0001) and their rhythmic activity (chi2 = 41.4, p < 0.0001) were seen on gray-scale sonography in an increasing percentage of fetuses as gestational age increased. Doppler findings showed an increase for nose-mouth flow signals (chi2 = 57.6, p < 0.0001), larynx-esophagus flow signals (chi2 = 13.2, p = 0.0003), and effective swallowing (chi2 = 36.0, p < 0.0001) as gestational age increased. CONCLUSION: There is a trend in the fetus toward development of increased coordinated movement and more functional nose-mouth flow with increasing gestational age: 32.1% of the 56 fetuses in our series achieved effective swallowing at 37-39 weeks, on the basis of gray-scale and Doppler evaluations. Knowledge of the physiologic mechanism involving swallowing development may allow identification of altered swallow-related movements in fetuses with malformations of the digestive tract or with neurologic disorders.

Abstract: PURPOSE: The aim of the present paper is to describe the normal radiological findings and the fragmentation time of the VALTRAC BAR (V-BAR). MATERIALS AND METHODS: Ten cases of Roux-en-Y jejuno-jejunostomy with anastomosis with a n.25 Valtrac ring for gastric cancer were followed up during the postoperative period by plain abdominal X-ray examination. RESULTS: Abdominal X-ray examination showed V-BAR fragmentation between day 14 and 21 after surgery. In one case only did fragmentation fail and the V-BAR migrated resulting in mechanical ileus. CONCLUSIONS: The possible non-fragmentation and migration of the V-BAR confirms the need to follow up patients with plain abdominal radiography performed at short intervals during the postoperative period.

Abstract: INTRODUCTION: Splenic and renal infarctions are usually related to vascular disease or haematologic abnormalities. Their association is infrequent and rarely observed in trauma. In this study, we analyze our data to look at the occurrence of renal and splenic infarctions based on CT findings in a period of 4 years. MATERIALS AND METHODS: We retrospectively reviewed the imaging findings of 84 patients admitted to our Department of Diagnostic Imaging from June 1998 to December 2002, who underwent emergency abdominal spiral CT examination and in whom there was evidence of splenic and/or renal infarction. RESULTS: We found 40 cases of splenic infarction and 54 cases of renal infarction, associated in 10 patients. In 26 patients, there was also evidence of intestinal infarction. A traumatic origin was found in 19 cases; non-traumatic causes were found in 65 patients. Association between renal and splenic infarction in the same patient was related to trauma in two cases. CONCLUSIONS: Although renal and splenic infarctions are a common manifestation of cardiac thromboembolism, other systemic pathologies, infections or trauma may lead to this occurrence. Renal infarction may be clinically and/or surgically managed with success in most cases. There are potential complications in splenic infarction, such as development of pseudocysts, abscesses, hemorrhage, subcapsular haematoma or splenic rupture; splenectomy in these cases may be necessary. Some patients with splenic and/or renal infarction may be clinically asymptomatic. The high accuracy of CT examination is needed to allow a correct evaluation of infarcted organs.

Abstract: The CT diagnosis of bowel and mesenteric injuries is difficult and warrants optimal technique and skilled interpretation. We retrospectively reviewed 36 consecutive patients with blunt traumatic injuries to the bowel and mesentery at our regional level I trauma center during the past 3 years. Physical examination, laboratory, Computed tomographic (CT), and intraoperative findings were compared. Surgically proven bowel injuries (13 cases) occurred in the duodenum (three cases), ileum (two cases), jejunum (two cases), colon (three cases), and stomach (three cases). CT findings considered specific of bowel rupture were observed in 5/13 patients including: extraluminal oral contrast or luminal content extravasation (four cases) and discontinuity of hollow viscus wall (one case). In the remaining 8/13 CT findings considered suggestive of bowel injury consisted of: pneumoperitoneum (six), gas bubbles close to the injured hollow viscus (three), thickened (>4-5mm) bowel wall (five), bowel wall hematoma (three), intraperitoneal fluid of unknown source (three). Mesenteric injury (23 cases) were surgically observed at the level of the mesenteric vessels (17 cases), legament of Treitz (two cases), gastro-duodenal artery (one case), transverse (one case) and sigmoid mesocolon (one case). CT finding considered specific of mesenteric laceration was active extravasation of contrast material from the mesenteric vessels (10 cases). CT findings suggestive of mesenteric injury (13 cases) consisted of: mesenteric hematoma (five) and/or high attenuation fluid collections, within the mesenteric root (eight) and folds (four). Helical CT is sensitive in the identification of bowel and mesenteric injury after blunt trauma providing a wide spectrum of findings. However, CT cannot be used as the sole indicator in cases with isolated thichened bowel wall, mesenteric hematoma, bowel hematoma, pneumoperitoneum or gas bubbles. Persistent, active extravasation of intravenous constrast medium from the mesenteric vessels, in isolation or associated with further injuries, requires immediate exploration and repair; disruption of bowel wall and extravasation of oral contrast are definite signs of bowel rupture. Close clinical observation, monitoring, and surgical expertise are mandatory for appropriate management.

Abstract: INTRODUCTION: Gastro-duodenal perforations may be suspected in patients with history of ulceration, who present with acute pain and abdominal wall rigidity, but radiological findings in these cases may be unable to confirm a clinical diagnosis. The aim of our study was to report our experience in the diagnosis of gastro-duodenal perforation by conventional radiography, US and CT examinations. MATERIAL AND METHODS: We retrospectively reviewed medical records of 166 consecutive patients who presented in the last 2 years to our institutions with symptoms of acute abdomen and submitted to surgery at the Emergency Unit of the "A.Cardarelli" Hospital of Naples with a surgical finding of perforated gastro-duodenal ulcer. The evidence of free intraperitoneal air on abdominal plain film was considered as a direct or suggestive finding of perforation. Evidence of intraperitoneal free fluid and/or reduced intestinal peristalsis at sonographic examination were considered indirect signs of gastro-duodenal perforation. Evidence of free peritoneal gas at CT was considered as a direct evidence of gastro-duodenal perforation. RESULTS: Twenty patients underwent immediate surgery with no preoperative imaging evaluation, in 10 of them the site of perforation was found in a juxta-pyloric region and in the others at level of duodenum. In 146 patients submitted to serial radiological investigations before surgery, the site of perforation was in 56 (38.3%) duodenal, in 52 (35.6%) juxta-pyloric, in 28 (19.1%) gastric and in 10 (6.8%) pyloric. The cause of perforation was in all cases gastric or duodenal ulceration, in seven cases involving pancreatic parenchyma. In 110 (75.4%) patients with direct findings of perforation, in 94 cases (85.5%) the correct diagnosis was established on abdominal plain film, in two (1.8%) with radiographic and sonographic examinations and in 14 (12.7%) on CT findings. In 36 (24,6%) patients with no direct findings of perforation, only 24 (16,4%) of them showed indirect findings of perforation. In other 12 patients no direct or indirect finding of free peritoneal air was detected. CONCLUSIONS: Our experience documents that in 146 gastroduodenal perforations the free peritoneal air was not evident in 12 cases and in 66% of these patients the presence of intraperitoneal fluid could be the only sign of perforation. If free peritoneal air was detected with conventional radiography, other investigations were not indicated. In the absence of direct or indirect findings of pneumoperitoneum, US examination could help to confirm intestinal paresis and the evidence of intraperitoneal free fluid. Helical CT examination was useless before at least 6h from the onset of symptomatology, because in the absence of direct or indirect findings of penumoperitoneum at abdominal plain film and sonograpy, CT could not demonstrate any additional diagnostic information.

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Abstract: PURPOSE: To assess the positive predictive value and the negative predictive value of spiral CT in the diagnosis of "closed-loop" obstruction complicated by intestinal ischaemia. MATERIALS AND METHODS: Between January 1999 and January 2002, 120 patients with small intestine closed-loop obstruction who had undergone surgical laparotomy within 2-6 hours from abdominal and pelvic spiral CT were retrospectively reviewed. The CT scans were performed using 5-mm slice thickness, 1 s scan delay, 5 x 5-mm collimation and 1.5 pitch after administering i.v. iodinated contrast material (120 ml volume, 60 s scan delay, 2.5-3 ml/s rate) with an automatic injector. For the diagnosis of closed-loop obstruction the following CT findings were examined: identification of the transitional area, 'C', 'U' or 'beak' shape of the obstructed loops, radial distribution of the involved mesenteric vessels. For the diagnosis of loop ischaemia, the following findings were evaluated in addition to the CT signs described above: submucosal oedema, increased, reduced, or no enhancement of the loop walls, oedema of the mesenteric vessels, fluid within the loops or in the intraperitoneal spaces. RESULTS: 'U', 'C', 'beak' loop configuration with poor or no contrast enhancement of the obstructed loop walls, ascites, rotation and engorgement of mesenteric vessels enabled the diagnosis of 26 cases of closed-loop obstruction complicated by ischaemia, infarction. U- or C-shaped loops with radial distribution and/or rotation of mesenteric vessels towards the obstruction site suggested the correct diagnosis in 94 cases, but did not allow identification of ischaemia in 25 cases. The positive predictive value of spiral CT related to ischaemic loop complications was 100%; the negative predictive value was 73%. CONCLUSIONS: Spiral CT is a reliable imaging technique enabling the diagnosis of closed-loop obstruction with or without intestinal ischaemic complications. Any alterations detected in the trophic status of the loops or mesentery imply ischaemic complications requiring emergency surgery. On the contrary, if only CT signs of closed-loop obstruction are detected, the existence and/or development of ischaemia cannot be ruled out.

Abstract: INTRODUCTION: The main role of the radiologist in the management of patients with suspicion of small bowel obstruction is to help triage patients into those that need immediate surgical intervention from those that require medical therapy or delayed surgery. Ultrasound examination is usually considered not helpful in bowel obstruction because of air in the intestinal lumen that interferes the evaluation of the intestinal loops, however recently some Authors attested the increasing important role of sonography in the acute abdominal disease. Aim of our report is to demonstrate the value of free fluid detected by US in differentiating between low and high-grade small bowel obstruction. MATERIALS AND METHODS: The study is based on 742 consecutive patients who presented symptoms of the acute abdomen; all patients had undergone initial serial abdominal plain film and US examinations prior to any medical intervention. We reviewed the imaging findings of 150 cases in whom small bowel obstruction was clinically suspected and confirmed at surgery. We consider the following radiographic and US findings: dilatation of small bowel loops; bowel wall thickness; presence of air-fluid levels; thickness of valvulae conniventes; evidence of peristalsis; presence and echogenicity of extraluminal fluid. We looked at the value of extraluminal peritoneal fluid at US examination in differentiating low and high-grade small bowel obstruction based on the surgical outcome. RESULTS: In 46 patients altered peristaltic activity, thin bowel walls, fluid filled loops with hyperechoic spots in the bowel segment proximal to obstruction were noted at US, whereas radiographic features were: moderate dilatation of small bowel loops, with thin bowel wall and evidence of numerous and subtle valvulae conniventes; presence of air-fluid levels was also noted. In 70 other patients, US examination revealed all the findings described in the precedent cases and also the presence of free extraluminal fluid; abdominal plain film showed an increased dilatation of small bowel loops with moderate thickened wall and air-fluid levels. In 34 other patients US examination revealed the presence of thick-walled loops, hypoperistalsis and a larger amount of free extraluminal fluid. Radiographic findings in these patients were: horizontal featured and markedly dilated small bowel loops presenting parietal thickness, presence of intraluminal fluid stasis and evidence of thickened, sparse and incomplete valvulae conniventes. At surgery etiology of small bowel obstructions was various, but most of cases related to adhesions (70 cases). The presence of extraluminal fluid were confirmed at surgery in 104 patients. CONCLUSIONS: Our experience using sonography in suspicion of SBO (small bowel obstruction) suggests the usefulness of this imaging modality to differentiate a functional or obstructive ileus, demonstrating the evidence of intestinal peristalsis. Furthermore, the presence of a large amount of fluid between dilated small bowel loops suggests worsening mechanical small bowel obstruction, that requires not a medical therapy but immediate surgery.

Abstract: In recent years the increasing use of ultrasonography and computed tomography in the assessment of diseases causing acute abdomen and the diagnostic possibilities of magnetic resonance have decreased the role of conventional radiology techniques, especially of plain abdominal film in the diagnosis of acute abdomen. However, serial plain abdominal film is still the first diagnostic procedure used in the assessment of patients with acute abdominal pain, providing important diagnostic information if correctly performed and carefully observed. In this paper serial plain abdominal film findings related to the different types of ileus (spastic ileus, hypotonic ileus, mechanical ileus and paralytic ileus) are presented.

Abstract: A case of gastrointestinal stromal tumor of stomach investigated with US, CT, and MRI is reported. On imaging, the neoplasm arises from the wall of the gastric fundus and appears well circumscribed and sharply demarcated from the adjacent structures. MRI provides an excellent means of evaluating the site and extension of this neoplasm and enables accurate surgical planning. The authors stress that there has been recently widespread scientific and clinical interest in GIST (gastrointestinal stromal tumor) because its principal pathogenetic defect has been identified and a specific molecular inhibitor of GIST has been developed.

Abstract: PURPOSE: To compare the site of multislice spiral computed tomography (MSCT) signs of gastrointestinal perforation and the site of perforation at surgery in forty perforated patients. MATERIALS AND METHODS: Between January 1 and July 31, 2003, a total of 40 patients (23 men and 17 women) underwent surgery for gastrointestinal perforation. In all cases, plain radiography of the abdomen was integrated by MSCT with the following parameters: 0.5 seconds gantry rotation time, 2.5-5.0 mm slice thickness, 3.75 reconstruction interval, 120 kV, 250-300 mAs, pitch 1.5, after intravenous administration of 140 ml of contrast agent at 3 ml/s with an automatic injector and a delay time of 70 seconds from the injection of the contrast agent. The MSCT findings were: free air and free fluid observed in supramesocolic compartments and/or in inframesocolic compartments and bowel wall discontinuity. The sites of the MSCT findings were compared with the site of perforation observed at surgery. RESULTS: Free air was detected in 60%, free intraperitoneal fluid in 92.5%, and a combination of both findings in 57.5% of the 40 cases examined. There were no cases of bowel wall discontinuity. In nine patients with gastroduodenal perforation, free air and free fluid were detected in combination and free air was localised in supramesocolic compartments in all cases; in two patients with jejunal perforation, free intraperitoneal fluid was observed both in supramesocolic and inframesocolic compartments; in six patients with acute perforated appendicitis, free air was never detected, while free fluid was observed in all cases in inframesocolic compartments; in six patients with isolated sigmoid perforation free air was observed in four cases in supramesocolic compartments while free fluid was seen in both supramesocolic and inframesocolic compartments. CONCLUSIONS: MSTC is the most reliable diagnostic method with which to assess gastrointestinal perforation as it allows detection of even small amounts of free air in the abdomen, which are a sign of perforation. In our study, the comparison of the sites of MSCT signs of perforation with those observed at surgery showed that in gastroduodenal perforations free air and free fluid are present in combination and free air is localised in supramesocolic compartments; in acute perforated appendicitis free air is absent, while free fluid is present in inframesocolic compartments; in isolated sigmoid perforations free air, if present, is localised in supramesocolic compartments, while free fluid is seen in both compartments.

Abstract: Conjoined twins can be classified on the basis of the site of union; thus, three main types can be described: (a) ventral union, (b) dorsal union, and (c) rarer forms of union. Ventral union is characterized by the fusion of the two embryos on the ventral side (eg, the abdomen). Dorsal union twins are joined on the dorsal aspect (eg, the vertebral column or occipital bone). Ventral union twins include the group of crucipage twins (ventral midline structures at 90 degrees to the dorsal midline structures), which show interesting features in the organization of the midline. Twins conjoined at the head and chest are called cephalothoracopagus twins. The cephalothoracopagus variety called "Janus" is characterized by the presence of two opposite faces, which are composite structures half of which belong to one twin and half to the other. A complete set of five variants of cephalothoracopagus is presented and, to the authors' knowledge, analyzed for the first time with multi-detector row helical computed tomography. This modality is an invaluable tool for obtaining high-resolution images of the brain, chest, abdomen, and spine and for demonstrating organ position, shared viscera, and limited vascular anatomy. In addition, data acquired in three-dimensional volumes can further be manipulated and then reconstructed. For this purpose, the authors developed dedicated software for three-dimensional reconstruction to analyze data from specimens preserved in formalin. The anatomic findings are discussed here for their embryologic value and to revise the classification of cephalothoracopagus twins. These data offer detailed information for accurate comprehension of imaging studies and for theoretical studies concerning the formation of several anatomic structures.

Abstract: We report a case of migration of a surgical localization wire from the breast to the abdomen. A 41-year-old female underwent presurgical needle localization of a deep-sited left-sided breast lesion. Migration of the localization wire in the chest wall occurred during the procedure documented by imaging. Computed tomography (CT) examination showed no evidence of the wire in the left lower lung field, no peritoneal free fluid, active bleeding, or abnormalities of abdominal organ, but a metallic-density representing the localization wire was seen for a length of 13 cm from the right diaphragmatic crus to the right psoas muscle, close to the inferior vena cava. A following CT examination showed the wire partially outside the inferior vena cava and partially inside the right iliac vein. The wire was successfully taken out by an angiographic interventional procedure.

Abstract: Leiomyosarcoma is a mesodermal malignant neoplasm affecting the small intestine. Usually, the clinical signs are not specific and most commonly related to intestinal bleeding or obstruction. We report the case of a 71-year-old woman presenting anemia and melena: there was no evidence of abdominal palpable mass and endoscopic examinations were negative for pathologic findings. We performed sonography and CT-enterclysis. We detected a small jejunal mass presenting a heterogeneous density and echogenicity pattern, with some large peripheral calcifications. Histologic examination after surgery revealed the lesion to be a small bowel leiomyosarcoma.

Abstract: Ependymomas outside the confines of the cranium and spinal cord are rare. Direct extension into the soft tissues of the sacrococcygeal area may occur from a primary ependymoma of the spinal cord, cauda equina or filum terminale. Alternatively they may occur as a primary pre-sacral, pelvic and abdominal tumour, or as a primary tumour of the skin and subcutaneous tissue of the sacrococcygeal area without any demonstrable connection with the spinal cord. The Authors report a case of myxopapillary ependymoma of the ischioanal fossa, demonstrated by MRI. To our knowledge, our case is the first lesion reported at this site.

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Abstract: Descending necrotizing mediastinitis (DNM) is a rare and life-threatening complication of deep neck space infection which occurs when infection spreads from the deep spaces of the neck, propagating within the soft tissue into the mediastinal spaces. The disease has a high mortality rate due to frequent delay in diagnosis and treatment. Computed Tomography (CT) is important in determining the level of infection, showing the presence and extension of fluid collections (with or without gas bubbles) and diffuse soft-tissue infiltration of the mediastinal fat, and indicating the best surgical approach and progress of treatment. Three cases of DNM evaluated with spiral CT from June 1999 to June 2001 are presented.

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Abstract: Small bowel metastases of lung cancer as unique secondary lesions are a very rare occurrence and may be clinically missed due to the aspecificity of the symptoms. Diagnosis is usually made at acute abdominal symptomatology that requires emergency surgical treatment. We report a case of 69-year-old woman, previously treated for epidermoid lung carcinoma, complaining only of aspecific asthenia; blood cell count and chemistry showed a moderate but progressive anemia; no signs of small bowel occlusion were present. The follow-up CT scan showed two large masses at the small bowel level, without any evidence of hepatic, lung, adrenal or brain metastases. MRI and small bowel enema confirmed the presence of the masses, and the diagnosis of small bowel metastases was hypothesized. Surgical specimens of the masses confirmed the radiological suspicion.

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Abstract: Several cases of a fat mass-like lesion adjacent to and/or projecting into the inferior vena cava have been presented as a normal variant of perioesophageal fat distribution or as intravascular lipoma. We report a case of a lipoma of the inferior vena cava, studied with coronal reformatted CT images, ultrasound and colour Doppler imaging, in a 78-year-old female patient.

Abstract: AIM: The present study provides a census of equipment in use by Radiodiagnostic Services in public hospitals and institutes recognized by the Region of Campania in the year 2000. The type, date of installation and distribution of the equipment were considered in relation to the number of hospital beds and the resident population. MATERIALS AND METHODS: A census was taken of all the public hospitals and institutes recognized by the Region of Campania in the period running from January 1999 to April 2000. Data were collected using an appropriate form asking for details of the number of machines and the model, manufacturer and year of installation, under six categories: traditional radiology, mammography, US, CT, MR and angiography. The data were analyzed by provinces, combining the different machines into five-year periods depending on the date of their installation. RESULTS: Traditional radiology equipment accounts for 71% of the total. The mean for the Region stands at 23 machines per 1000 beds. The mean date of installation was 1986. Mammography machines account for 8% of the total. The mean for the Region stands at 2.6 machines per 1000 beds. The mean date of installation was 1991. Echography machines account for 10.3% of the total. The mean for the Region stands at 3.4 machines per 1000 beds. The mean date of installation was 1992. Angiography machines account for 3.2% of the total. The mean for the Region stands at 1.1 machines per 1000 beds. The mean date of installation was 1985. CTs account for 6.4% of the total. The mean for the Region stands at 2.1 machines per 1000 beds. The mean date of installation was 1993. MR account for 1.1% of the total. The mean for the Region stands at 0.4 machines per 1000 beds. The mean date of installation was 1995. CONCLUSIONS: Technological and scientific improvements and growing attention to the quality of medical care expected by patients mean that constant modification and adaptation are needed to meet demands. In planning measures designed to provide new radiological equipment and modernize existing equipment in the Region it would certainly be useful to eliminate the unevenness of the services provided. In conclusion, it is crucial that the local administrations and health authorities in the Campania Region establish a regular census, with proper assessment of the obsolescence of radiological equipment and its distribution throughout the area, in order to comply with international standards.

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Abstract: Portomesenteric pneumatosis has been traditionally associated with intestinal infarction and poor outcome; however, recent studies have questioned its clinical value. To assess its diagnostic and prognostic significance we have retrospectively evaluated 47 patients correlating the CT finding of portomesenteric vein gas with clinical data and outcome. Thirty-nine patients (83%) had surgical evidence of intestinal infarction, four had necrotic small bowel volvulus (8.5%), two had blunt trauma, one had necrotic gastric volvulus, and one a gastric mucosal lesion induced by a nasogastric tube. Fifteen patients survived (31.9%); only 8/39 patients with intestinal infarction survived. Portomesenteric pneumatosis is a reliable marker of intestinal infarction and poor outcome; however, in trauma patients this sign is associated with a better prognosis.

Abstract: OBJECTIVE: The purpose of this retrospective study was to determine the value of contrast-enhanced computed tomography (CT) in the detection and management of mesenteric injuries after blunt trauma. MATERIALS AND METHODS: Between June 1995 and December 2000, 1,619 consecutive abdominal CT examinations were performed in the setting of major blunt trauma. Findings at CT were evaluated before patients were classified as having grade 1 or grade 2 lesions or none. Grade 1 represented the presence of minor injuries: mesenteric haziness, confined fluid, and/or small hematomas (<30 mm) within the mesenteric folds and abdominal injuries; grade 2 was appropriate to evidence of major injuries: moderate to large hematomas (>30 mm), active bleeding, hemoperitoneum, and further abdominal injuries. RESULTS: On the basis of the CT findings, 161 (9.9%) of 1,619 patients were classified as having grade 1 and 25 (1.5%) of 1,619 patients as having grade 2 injuries. Of the 161 (77.6%) patients with grade 1 injuries, 125 were managed conservatively, while 36 (22.4%) underwent surgery. Of the 25 (84%) patients with grade 2 injuries, 21 were treated surgically and 1 (4%) patient was followed medically. Three (12%) of the 25 patients underwent laparotomy after 24 h close clinical observation and monitoring. Initial CT findings in 1,433 (88%) of the 1,619 patients were negative for mesenteric injuries, and in 1,430 of these cases no delayed mesenteric hemorrhage was observed. CONCLUSION: Contrast-enhanced CT has a critical role in the identification and exclusion of mesenteric injuries. Persistent, active extravasation of contrast material, in isolation or associated with further abdominal lesions, is a sign of a high likelihood of injury requiring urgent laparotomy. Haziness, isolated confined clotted mesenteric hemorrhage, and small hematomas within the mesentery are nonspecific findings and should be considered in the appropriate clinical context. Close clinical observation, monitoring, and surgical expertise are mandatory for appropriate management.

Abstract: AIM: The authors report the results observed in apparently healthy young adults undergoing chest radiography for pre-employment screening. MATERIALS AND METHODS: Between July 1996 and December 1997, 2292 young adults underwent conventional chest radiography for pre-employment screening purposes. Of these, 378 subjects (16.4%) in whom the chest X-ray showed alterations indicative for pulmonary parenchymal lesions were selected for the study. The lesions were divided into four groups: 1) single nodular opacity (n=98/378=25.9%); 2) multiple nodular opacities (n=25/378=6.6%); 3) single or multiple parenchymal consolidation(s) (n=203/378= 53.7%); 4) interstitial disease ( %). All subjects received a tuberculin skin test. The subjects in groups 1, 2 and 3 underwent the diagnostic protocol, which consisted of tuberculin skin test (TST) and CT scan for groups 1 and 2, and a repeat chest radiograph at 30 days for group 3. The subjects in group 4 were studied by high-resolution CT (HRCT). RESULTS: In group 1, CT showed nodular opacities with psammomatous calcifications in 13 cases, vascular dilatations in 3, calcified nodule in 7 subjects with positive TST, and uncalcified nodular lesions in 75 subjects (53/75 with positive TST). In group 2, FNAB confirmed the preliminary diagnosis of metastases in 2 cases; CT demonstrated the pleural origin of opacities in 1 patient, and multiple nodular lesions in 12 subjects; it invalidated the radiographic findings in 3 subjects, and demonstrated multiple nodules associated to increased interstitial thickening in 3 subjects. In group 3, the lung alterations had completely disappeared in 106 subjects, whereas in 97 subjects there was reduced extension of the previously observed lesions, but appearance of new sites of parenchymal consolidation. In group 4 CT confirmed the radiographic suspicion in 14 cases. CONCLUSIONS: Tubercular infection is currently increasing in industrialised countries. In our study it showed a relatively high prevalence of about 4.5% in a young asymptomatic population.

Abstract: The purpose of this retrospective study was to determine the value of contrast-enhanced helical CT for detecting and managing acute thoracic aortic injury (ATAI). Between June 1995 and February 2000, 1419 consecutive chest CT examinations were performed in the setting of major blunt trauma. The following CT findings were considered indicative of ATAI: intimal flap; pseudoaneurysm; contour irregularity; lumen abnormality; and extravasation of contrast material. On the basis of these direct findings no further diagnostic investigations were performed. Isolated mediastinal hematoma on CT scans was considered an indirect sign of ATAI: In these cases, thoracic aortography was performed even if CT indicated normal aorta. Seventy-seven patients had abnormal CT scans: Among the 23 patients with direct CT signs, acute thoracic aortic injuries was confirmed at thoracotomy in 21. Two false-positive cases were observed. The 54 remaining patients had isolated mediastinal hematoma without aortic injuries at CT and corresponding negative angiograms. The 1342 patients with negative CT scans were included in the 8-month follow-up program and did not show any adverse sequela based on clinical and radiographic criteria. Contrast-enhanced helical CT has a critical role in the exclusion of thoracic aortic injuries in patient with major blunt chest trauma and prevents unnecessary thoracic aortography. Direct CT signs of ATAI do not require further diagnostic investigations to confirm the diagnosis: Isolated aortic bands or contour vessel abnormalities should be first considered as possible artifacts or related to non-traumatic etiologies especially when mediastinal hematoma is absent. In cases of isolated mediastinal hematoma other possible sources of bleeding should be considered before directing patients to thoracic aortography.

Abstract: INTRODUCTION: Small and large bowel mesenteric injuries from blunt abdominal trauma are rare and often difficult to diagnose. Computed Tomography used in cases of blunt abdominal trauma has been found sensitive in detection of bowel and mesenteric injuries and discrimination of operable from nonoperable candidates. PURPOSE: A retrospective study of the CT examination of 24 patients, with surgically confirmed bowel and mesenteric injuries, was performed. Our goal was to evaluate the various CT signs of blunt bowel and mesenteric injury and the related frequency. MATERIAL AND METHODS: Our series includes 24 patients, 16 of them (first group) were investigated with CT at Cardarelli Hospital, Naples, while the remaining 8 (second group) at University of Bari. Patients of the first group, 11 men and 5 women, age ranging from 18 to 77 years, were submitted to a conventional abdominal CT performed after i.v. administration of contrast media. Patients of the second group, 7 men and 1 woman, age ranging from 4 to 81 years, were submitted to helical CT performed with the following parameters: 10 mm slice thickness, 5-mm contiguous intervals from the level of the diaphragm to the pubic bone, pitch 1.5. Helical CT was performed in all cases before and after i.v. administration of contrast material injected at a rate of 3.5 ml/sec. A scanning delay of 40 seconds after the beginning of contrast injection was routinely used. In all patients the following CT signs were retrospectively searched on: peritoneal or retroperitoneal fluid, mesenteric hematoma, hazy streaky changes in mesenteric fat, high-density clot (sentinel clot) adjacent to the involved bowel, pneumoperitoneum, retropneumoperitoneum, extravasation of intravenous contrast material, bowel wall thickening. RESULTS: In the first group the following CT signs were observed: mesenteric hematoma (87.5%), hazy streaky changes in mesenteric fat (56.25%), peritoneal or retroperitoneal fluid (37.5%), sentinel clot (25%), bowel wall thickening (18.75%), extravasation of intravenous contrast material (12.5%). In the second group the following CT signs were observed: peritoneal or retroperitoneal fluid (87.5%), bowel wall thickening (50%), mesenteric hematoma (37.5%), sentinel clot (25%), pneumoperitoneum (12.5%), retropneumoperitoneum (12.5%), hazy streaky changes in mesenteric fat (12.5%). DISCUSSION AND CONCLUSIONS: Bowel and mesenteric injuries from blunt trauma are infrequent and difficult to diagnose clinically, as the physical and laboratory findings may be subtle and are often overshadowed by other injuries in patients with multisystem trauma. CT represents a proven modality in the evaluation of bowel and mesenteric injuries: careful inspection and technique are required to detect often subtle findings. In our series of 24 patients with surgically confirmed bowel and mesenteric injuries, the presence of mesenteric hematoma and of peritoneal or retroperitoneal fluid were the more frequent CT signs observed. Radiologists may play a crucial role in the timely diagnosis of these injuries, allowing prompt and appropriate management of these patients.

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Abstract: PURPOSE: Acute cholecystitis is one of the most frequent abdominal inflammatory processes. If untreated or misdiagnosed it can result in severe complications such as gallbladder rupture, abscesses, or peritonitis. We retrospectively reviewed a series of 71 consecutive patients with surgical confirmation of acute cholecystitis and now compare the results of the diagnostic techniques we used preoperatively. MATERIAL AND METHODS: Over 16 months, 71 consecutive patients (42 women and 29 men; age range: 34-84 years, mean: 58) with acute abdominal pain were operated on for acute cholecystitis at Cardarelli Hospital, Naples. Abdominal plain film was performed in 65 of 71 cases, abdominal US in 69 and abdominal CT in 6. On abdominal plain films, we retrospectively searched the following signs: densities projected over the gallbladder, linear calcifications in gallbladder walls, gallbladder enlargement, focal gas collections within the gallbladder, and air-fluid levels in the gallbladder lumen. On US images we looked for: gallbladder wall thickening (> 3 mm), intraluminal content in the gallbladder, pericholecystic fluid, US Murphy's sign, and gallbladder distension. On CT images, we investigated: gallbladder distension, wall thickening, intraluminal content, pericholecystic fluid, and inflammatory changes in pericholecystic fat. Associated complications of cholecystitis were also searched on all images. RESULTS: On plain abdominal films we found densities projected over the gallbladder (16.9%) and linear calcifications in the gallbladder wall (4.6%). Abdominal US demonstrated gallbladder wall thickening (56.5%), one or more gallstone(s) (85.5%), pericholecystic fluid (14.5%), gallbladder distension (46.4%), and US Murphy's sign (39.1%). Abdominal CT showed gallbladder wall thickening (83.3%), gallbladder distension (66.6%), pericholecystic fluid (66.6%), gallstones (50%), inflammatory changes in pericholecystic fat (33.3%), and increased bile density (> 20 HU) (33.3%). CONCLUSIONS: US appears to be the most useful imaging technique in patients with suspected acute cholecystitis, for both screening and final diagnosis. CT plays a limited role in the early assessment of these patients, but can be a useful tool in diagnosing acute cholecystitis in patients with questionable physical findings or in investigating related complications.

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Abstract: PURPOSE: To evaluate the effectiveness and role of CT in blunt diaphragmatic injuries by reviewing our 8-year experience. MATERIAL AND METHODS: We reviewed the preoperative CT findings of 35 patients with surgically confirmed diaphragmatic rupture. Surgical repair was performed in the acute setting (within 12 hours of trauma) in 22 cases, and late (8 months-5 years) in 13 cases. Twenty-eight patients (80%) were examined with conventional CT and 7 (20%) with Helical CT. Scans were initiated at the thoracic inlet to the pubic symphysis, with 8-mm slice thickness, after i.v. contrast agent administration. Four-mm slices were acquired in the region of interest; sagittal and coronal reformations were obtained for Helical CT images. RESULTS: In the acute group, 20 patients had left hemidiaphragmatic and 2 right hemidiaphragmatic rupture; thoracic herniation of the abdominal organs was seen in all cases. Of the 13 patients examined long after trauma, the left hemidiaphragm was ruptured in 12 cases (with visceral herniation in 4), and the right hemidiaphragm in 1, with no herniation. The diaphragmatic rent was found in the dome (15 cases, 43%), musculotendinous junction (11 cases, 31%), muscular portion (8 cases, 23%), and at the muscular attachments on the ribs (1 case, 3%). CT diagnosed diaphragmatic rupture in all the acute cases (22/35 patients, 63%) and in 4 patients with visceral herniation (11%) examined long after trauma. CT findings were questionable in the 9 cases (25%) not presenting visceral herniation. As for the site of diaphragmatic injury, CT never depicted the diaphragmatic rent in the dome and at the musculotendinous junction (74%), not even with thin slices and the multiplanar Helical technique. CT detected indirects signs of injury at the muscular portion (23%), showing the injury site directly in the case with diaphragmatic avulsion (3%). CONCLUSION: CT is a reliable tool in the diagnosis of suspected diaphragmatic injury in the acute trauma setting. Long after trauma, CT performs poorly because it depicts the diaphragmatic rent only in some peripheral traumas. Helical CT has greater diagnostic potentials, but the injury site and type do affect its capabilities.

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Abstract: We describe the case of a 35-year-old man who had suffered a severe multitrauma with blunt thoracic injury, left scapula and humerus fractures 5 years earlier. At the time of the trauma, a diaphragmatic lesion went unnoticed. Five years later, the patient had a 24-h history of increasingly severe abdominal pain with repeated vomiting. Helical CT showed a portion of the left hemidiaphragm avulsed from its insertions on the ribs with large-bowel loop obstruction herniated in the left hemithorax. The preoperative CT diagnosis was confirmed by surgery: reduction of the hernia and reinsertion of the hemidiaphragm to the lumbocostal arch were performed.

Abstract: PURPOSE: To demonstrate the usefulness of CT findings in the planning of brain neurosurgery in gunshot victims, for prompt and successful treatment. MATERIAL AND METHODS: Thirty patients with brain gunshot wounds were examined with CT over 5 years. The patients were 27 men and 3 women whose mean age was 33 years (range: 17-56). Brain CT was carried out with thin (5-mm) slices and 10-mm gap; dynamic scanning (3-mm interscan time) was used especially in case of posterior fossa involvement and diffuse brain damage. The examination was integrated with cervical scout views to detect bullets in the neck and cervical dislocation. CT follow-up was carried out in 20 patients 24 hours postoperatively and every 6 hours in 9 patients in a severe postoperative coma. RESULTS: Twelve intracranial hematomas and 9 subdural hematomas, 3 of them bilateral, were treated and hemorrhage was resolved in 8 lacerocontusive foci. Skull plastic surgery was carried out in 5 cases. Surgical maneuvers were most difficult in the 5 crash bone injuries with wedged splinters; postoperative subarachnoid hemorrhage followed in 3 cases. Blood effusion in ventricles was drained in 6 cases; in 2 of them with permanent catheters. Eleven patients died: 4 right after surgery and 7 an average 15 days postoperatively. DISCUSSION AND CONCLUSIONS: In our series the mortality rate of firearm wounds of the skull base was 34% higher than that of the hemisphere; this is due to carotid hemorrhage and midbrain damage. Such traumas require emergency radiological diagnosis and neurosurgical treatment because of their severity and early irreversible complications. Complex operations and skilled surgeons may prevent disabling postoperative sequels. CT findings are indispensable and must be correctly interpreted. The radiologist and the neurosurgeon must collaborate closely and both must consider several diagnostic and prognostic factors affecting surgical planning.

Abstract: INTRODUCTION: We investigated the diagnostic accuracy of unenhanced helical CT in the detection of stones in patients with suspected renal colic from ureteral stones and compared CT findings with the results of plain abdominal film and US. MATERIAL AND METHODS: We reviewed the findings relative to 80 patients (age range 24-75) who came to our observation to the Emergency Department with acute flank pain. All patients had been examined with plain abdominal radiography, US and unenhanced helical CT. RESULTS: While abdominal radiography showed the presence of radiopaque stones in 38 patients only (47.5%), US demonstrated ureter dilatation in 72 patients and detected stones in 36 of them (45%). Helical CT performed best, depicting a stone in 72 patients (90%), with high sensitivity and specificity. Mean stone size was 3 mm, with 7 mm-1 mm range. The biggest stones were seen in 3 cases and the smallest ones in 34. In 8 patients with no signs of stones we found other extraurinary conditions, namely pancreatitis, diverticula, renal cancer. We also found a case of urinary tract infection. CONCLUSIONS: Thanks to its short execution time and accuracy, helical CT makes the examination of choice in patients with acute flank pain due to renal colic. It is also a most valuable tool in the differential diagnosis of other pathological causes of pain such as abdominal or pelvic masses and inflammatory conditions.

Abstract: We report a case of male breast metastasis from a urothelial carcinoma. Only two cases of this type of metastasis have been previously reported, and these were in the female breast. Clinical examination showed a progressive swelling of the left mammary region, with periareolar skin infiltration. Both mammography and ultrasound showed a rounded mass. Only histological examination with immunohistochemical staining permitted the correct diagnosis to be made. A particular feature of the present case is the absence of contralateral gynaecomastia, normally seen in cases of metastatic tumour to the breast from prostatic carcinoma.

Abstract: PURPOSE: Colonic diverticula are saccules made of colonic mucosa and submucosa that herniate from the colonic lumen through the muscular layer of the wall where straight vessels penetrate. Diverticula are localized in the sigmoid colon in 95% of cases. Bacteria pooling in the lumen may cause lumen erosion and eventually perforation. CT is a useful technique in this condition because it can demonstrate intra- and/or extramural inflammation. Aim of this retrospective study was to assess the capabilities of contrast-enhanced helical Computed Tomography (CT) in sigmoid diverticulitis, especially relative to selection of the appropriate treatment. MATERIAL AND METHODS: We retrospectively reviewed the findings of 41 patients referred to our emergency department for diverticulitis. CT scans were performed 65 seconds after i.v. injection of nonionic contrast material (3 mL/s, 120 mL in all) administered by a CT-power injector. The following 7 CT findings were considered at least suggestive of acute diverticulitis: focal wall thickening, intramural abscess, inflammatory changes in the sigmoid mesentery root, pericolic fat inflammation or pericolic abscess formation, fistula, peritonitis. CT results were compared with surgical and physical findings. RESULTS: Based on CT findings, diverticulitis was classified as mild (25 patients) or severe (15 patients). In mild diverticulitis we found: focal sigmoid wall thickening (6 patients), intramural abscess (3 patients), sigmoid mesentery root thickening (5 patients), edema fluid (8 patients) and phlegmon (3 patients). In severe diverticulitis we found: sigmoid mesentery abscess (6 patients), fistula (5 patients) and peritonitis (4 patients). CT findings were questionable in 1 case and thus we could not exclude a perforated carcinoma. CONCLUSION: Contrast-enhanced helical CT is the imaging modality of choice in assessing mild or severe acute diverticulitis because it provides useful information for appropriate treatment planning in the emergency setting. This technique is most useful in questionable cases and in patients with suspected severe diverticulitis where a choice must be made between different treatment options.

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Abstract: PURPOSE: To report our personal experience in 48 patients with external rectal prolapse examined with defecography, evaluating radiological signs and the indications for surgical treatment. We also report the results of 7 patients with severe prolapse submitted to dynamic CT of pelvis. MATERIAL AND METHODS: The findings relative to 48 patients suffering from external prolapse, 27 women and 21 men, (mean age 58 years), were retrospectively reviewed. In our study protocol the patient is made to sit on a defecographic commode with the pelvis in lateral projection and radiographic images are acquired at rest, on contraction and on evacuation. Dynamic CT of pelvis with axial and coronal scans of the pelvic floor was carried out in 7 patients with severe prolapses. Twenty-six of 48 patients underwent rectopexy. RESULTS: The main symptoms were anorectal and perineal weight sensation (93%), perineal disturbance in the sitting position (91%) and anorectal pain extended to sacral area (83%). Manometry, which was performed in 36 cases, showed a rectoanal inhibitory reflex evokable at high volumes of air, especially in incontinent subjects. Defecography demonstrated external rectal prolapse in all cases; rectal intussusception in 32, mucosal prolapse in 30, abnormal widening of the anorectal angle in 24 (16 of them were incontinent), rectocele in 22 and perineal descent syndrome in 16 cases. DISCUSSION AND CONCLUSIONS: External rectal prolapse is sometimes a dynamic progression of a rectal intussusception. In anorectal intussusceptions, the invaginatum involves the anal canal, thus causing the external prolapse. Defecography clearly shows the continuation of invagination out of the anus, with the formation of prolapse. Dynamic CT proved accurate in detecting the rectum morphology, but added no further information to defecography, except for the diastasis of anosphincterial muscles. Therefore, we conclude that defecography is the method of choice, though complementary to other instrumental techniques such as manometry, electromyography and endoscopy, in the diagnostic workup of these patients. Moreover, it can recognize other alterations, such as incontinence and rectocele, which can be submitted to surgical correction with rectopexy.

Abstract: PURPOSE: To report our personal experience with the clinical and radiological diagnostic approach to stab and cut wounds of the thoracic cage and its content, a type of injury whose diagnosis and treatment, as well as the surgical approach, vary case by case. CT of deep penetrating wounds permits correct assessment of severe changes such as pneumothorax, hemothorax and pneumomediastinum. MATERIAL AND METHODS: In the last three years we examined 57 patients (48 men and 9 women; mean age 34 years, range 16-54): chest radiography was performed in 51 of them, with orthogonal projections in the standing and sitting positions. Chest CT was performed in emergency with i.v. contrast agent injection, with scans from the midneck to the diaphragm insertion to study border regions. Thoracostomy with pleural drainage was performed in 35 patients with pneumothorax and hemothorax while thoracotomy was performed in 8 patients, namely 4 with injury to the diaphragm, 2 to the heart, 1 with tear of the main bronchial artery and 1 of the aortic arch. RESULTS: The most frequent symptoms we found were chest pain (100% of cases) and dyspnea (84%); laboratory data showed anemia and decreased hematocrit levels in 28 cases. Chest radiography was negative in 14 cases. The patients were then examined with CT to exclude radiographic underestimation of minimal pneumothorax, small lacerocontusive or hemorrhagic foci and hemothorax, which were observed in 4, 2 and one cases, respectively, and where radiography was actually negative for traumatic changes. Chest radiography was positive in 43 cases: the most frequent finding was pneumothorax, with 37 cases (86%)--8 of them associated with hemothorax and 5 with pneumomediastinum. Lacero-hemorrhagic foci of lung parenchyma were found in 5 cases and single pulmonary hematoma from punch crossing was seen in 1 case. DISCUSSION AND CONCLUSIONS: CT was an accurate tool and had higher sensitivity than chest radiography in detecting and detailing pneumothorax, pneumomediastinum and lacero-hemorrhagic foci, as well as in quantifying hemothorax. Chest radiography had 12% false negatives and therefore we decided to perform CT in all the patients with penetrating wounds to prevent radiographic underestimation. Given the low rate of false negatives (7/57 cases) CT might appear superfluous but since in 2 of these 7 cases we had massive pneumothorax and pneumomediastinum associated with neck emphysema we suggest its use to prevent complications, clinical failures and medicolegal problems. CT permits correct assessment of penetrating stab and cut wounds of the chest and efficient and targeted treatment, which can be conservative, with thoracostomy with pleural drainage, or surgical.

Abstract: The small bowel angiodysplasia is a rare entity that causes lower intestinal bleeding; the diagnosis is difficult and based on selective angiogram.In our case, an 85-year-old woman was hospitalized after frequent episodes of melena. We performed an enema-helical CT abdominal examination before and after contrast medium administration per venam, detecting some increased intensity areas that surgery confirmed to be a vascular dysplasia on the jejunal first loop. We found the source of hemorrhage without performing an angiographic examination.

Abstract: INTRODUCTION: Expansive masses arising from periskeletal soft tissues are a frequent challenge for the imaging specialist. Lesion diagnosis and characterization, and the assessment of benign/malignant nature are very important factors for treatment planning. We investigated MR capabilities in distinguishing benign from malignant masses and for histopathologic lesion characterization, also in the light of the latest most authoritative literature reports. MATERIAL AND METHODS: February 1995 to November 1997, we examined 237 patients with known space-occupying lesions arising from periskeletal soft tissues. T1- and PD/T2-weighted SE images were acquired on the most suitable planes. The findings were independently evaluated by two groups of radiologists who were asked a benignity/malignancy judgment based on specific morphological criteria and then a presumptive histopathologic characterization. The results were then compared with pathologic findings. RESULTS: We had high agreement rates for benignity/malignancy judgements, with only < or = 3.8% error rates. In contrast, rates were quite variable for histopathologic characterization and differed greatly by lesion type. The lesions, defined as malignant, could not be characterized histologically in approximately 18% of cases by both groups. DISCUSSION AND CONCLUSIONS: Our results, which are in substantial agreement with the recent authoritative literature, confirm MRI as an extremely reliable tool for distinguishing benign from malignant expansive masses arising from periskeletal soft tissues. On the contrary, MRI exhibits good specificity in histopathologic characterization only for the masses with such development as to permit identification of the anatomical compartment of origin, which are usually benign, as well as the masses with typical or pathognomonic tissue signal.

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Abstract: INTRODUCTION: We retrospectively reviewed the CT findings of the acute abdomen patients examined in the last two years to investigate the frequency of a new CT sign of intestinal infarction, the pneumoretroperitoneum, and its association with other CT findings highly suggestive of this condition. MATERIAL AND METHODS: The CT findings of 60 patients with diagnostic confirmation of intestinal infarction were retrospectively reviewed. CT was performed without (no. = 55) and with (no. = 5) oral administration of contrast material and without (no. = 3) and with (no. = 57) the i.v. injection of nonionic contrast agents in repeated 50 mL boluses. To assess the specificity of this sign, we selected a control group of 400 patients submitted to CT for acute abdomen, but not blunt trauma; 19 of these patients had pneumoretroperitoneum. RESULTS: Pneumoperitoneum was found in five patients with intestinal infarction; it was an isolated sign in two cases and it was associated with few small perihepatic air bubbles in one case. Finally, it was associated with highly suggestive findings of late intestinal infarction in the other two cases. All cases of pneumoretroperitoneum in the control group had been correctly referred to other diseases by previous plain film and/or CT findings and surgery and/or endoscopy confirmed this diagnosis. DISCUSSION AND CONCLUSIONS: Pneumoretroperitoneum has been described as a complication of different benign or severe disorders; prompt recognition of its origin is essential since surgical and/or septic conditions may be involved. However, if the patient's history is negative for abdominal trauma, gastroduodenal ulcer or sepsis, pneumoretroperitoneum is generally cured with conservative treatment. Intestinal infarction or severe ischemia, a usually surgical conditions, should be considered among the different causes of pneumoretroperitoneum alone or associated with pneumoperitoneum or with highly suggestive late findings of infarction such as portal venous gas or pneumatosis intestinalis. This sign had a non-negligible incidence in intestinal infarction in our review (8.5%), but it should be known of and sought with specific window setting to enhance gas depiction on CT images to avoid false negatives.

Abstract: PURPOSE: To evaluate conventional radiography, US and CT in identifying jejuno-ileal perforation. MATERIAL AND METHODS: We retrospectively reviewed the findings of conventional radiography, US and CT in 13 consecutive patients with surgically proven jejuno-ileal perforation. RESULTS: The site of perforation was the ileum in 10 cases and the jejunum in 3 cases. Free gas was identified in 6 cases (46%) while indirect findings of perforation were found in 7 (54%). The jejunal perforations were diagnosed by indirect findings in all 3 cases. The ileal perforations were diagnosed by direct findings in 6 cases and indirect findings in 4 cases. CONCLUSION: Conventional radiology did not detect free gas in 7 (54%) of the 13 patients examined. In the absence of free gas, radiology showed indirect signs in all 7 patients, the most common being intraperitoneal free fluid in 5 (71%) of them. Jejunal perforations were more rare than ileal perforations and more difficult to identify by radiology. US was not useful for detecting free gas but it was useful for identifying intraperitoneal free fluid and intestinal paresis. Abdominal CT was useful when performed 6 h after the symptoms began.

Abstract: INTRODUCTION: Gallstone ileus is a mechanical obstruction of the gastrointestinal tract caused by the impaction of one or more gallstones within the bowel lumen. The insidious clinical presentation and the lack of specific signs of biliary disease are responsible for the delayed preoperative diagnosis which leads to an overall mortality rate of 15%. MATERIAL AND METHODS: A series of 9 consecutive patients (7 women and 2 men, age ranging from 17 to 83 years), with surgically proved gallstone ileus, was retrospectively reviewed: the authors report the radiologic procedures performed preoperatively and the diagnostic findings. Plain abdominal radiographs were performed in 4 of 9 patients, abdominal US in 4 and CT in 7 patients. All radiologic examinations were retrospectively reviewed by all authors independently, to recognize the different signs of gallstone ileus. RESULTS: The signs of Rigler's triad (small bowel obstruction, ectopic gallstones and air in the biliary tree) were observed on plain abdominal films in two cases, and ectopic gallstones and pneumobilia in two cases. The ectopic gallstones and the small bowel obstruction were demonstrated on abdominal US images in three cases. Rigler's triad was identified on abdominal CT images in 4 cases, while two findings (small bowel obstruction and ectopic gallstones) were observed in three cases. CONCLUSIONS: When the bowel is obstructed by a radiopaque calcified stone, plain radiographs and US of the abdomen are usually enough to diagnose gallstone ileus and no further studies are required.

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: INTRODUCTION: Solitary rectal ulcer syndrome is a complex evacuation disorder characterized by a benign ulcerative lesion of the distal rectum; the main symptom is rectal bleeding, but mucus discharge and difficult evacuation may be associated. The clinical, endoscopic and radiologic findings of solitary rectal ulcer syndrome are evaluated in this study. The role of defecography in the diagnosis of mucosal ulceration and morphofunctional alterations such as rectal prolapse and intussusception are investigated. MATERIAL AND METHODS: In the last 5 years, 27 patients (19 women and 8 men; mean age: 38 years; range: 13-70 years) complaining of obstructed evacuation and rectal bleeding were examined with fibrosigmoidoscopy with biopsy, and defecography combined with videoproctography. Defecography was carried out sitting the patients on a defecographic chair with the pelvis in lateral projection. The images were acquired at rest, under straining, during squeezing and evacuation. RESULTS: Endoscopy and biopsy showed 21 cases of solitary ulcer (77.8%), 3 cases of multiple ulcers (11.1%), 2 cases of granular proctitis (7.4%) and 1 case of pseudopolyp of rectum (3.7%). Among anorectal dynamic alterations, only 1 case (3.7%) of large rectocele was detected at endoscopy under straining. Histo-pathological changes were compared according to Rutter and Riddel criteria; the "colitis cystica profunda" appearance was observed in 2 cases (7.4%). Defecography showed 18 cases (16.6%) of solitary ulcer, 1 case (3.7%) of multiple ulcers and 2 cases (7.4%) of granular proctitis; but it missed 3 cases (11.1%) of small solitary ulcer, 2 cases (7.4%) of small multiple ulcers, and 1 case (3.7%) of pseudopolyp. The dynamic abnormalities shown by defecography were 11 cases (40.7%) of rectal intussusception, 7 cases (25.9%) of recto-anal intussusception, 6 cases (22.2%) of external rectal prolapse and 8 cases (29.6%) of mucosal prolapse. In 16 patients (59.2%) videoprotography emphasized how the ulcer wall was the first to take part in the invagination complex. CONCLUSIONS: Double contrast barium enema represents a useful radiologic method to diagnose solitary rectal ulcer, but air insufflation and pharmacological hypotonia prevent the functional study of rectal walls. Endoscopy permits to detect mucosal ulcerations, erythema, pseudopolyps and granular proctitis; biopsy provides an accurate diagnosis. We suggest combined defecography and videoproctography as a useful tool for evaluating solitary rectal ulcer syndrome as a whole; defecography is necessary to identify associated functional abnormalities, such as rectal prolapse and intussusception, not detectable by other instrumental and radiologic investigations and considered by many authors the likely cause of the disease.

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Abstract: INTRODUCTION: The most frequent cause of pneumoperitoneum is gastroduodenal ulcer. Perforations of the small bowel are uncommon compared with perforations of the rest of the alimentary tract and radiological findings of jejunoileal perforation have not been frequently reported. The aim of our retrospective study was to assess the CT findings in 18 patients with jejunoileal perforation. MATERIAL AND METHODS: We retrospectively reviewed the CT findings in 18 patients (12 men and 6 women, age ranging 14 to 84 years, mean age 42 years) operated for jejunoileal perforation at Cardarelli Hospital, Naples. CT examination was performed in all patients after i.v. injection of contrast medium and in two cases after oral contrast medium administration. Free intraperitoneal air, extravasation of ingested contrast media and visualization of a discontinuity in the bowel wall were considered direct findings of jejunoileal perforation, while intraperitoneal free fluid, thickened bowel wall and the presence of a streaky density within the mesentery were considered indirect diagnostic findings. RESULTS: The site of perforation was the jejunum in 6 cases and the ileum in 12 cases. The following CT findings were retrospectively observed: intraperitoneal free fluid (61%), free intraperitoneal air (33%), thickened bowel wall (22.2%), presence of a streaky density within the mesentery (5.5%). Visualization of a discontinuity in the bowel wall and extravasation of ingested contrast media were never seen. We observed two findings of perforation in 7 cases, and a single finding in 8 cases. CT examination was negative in 3 cases. CONCLUSIONS: Jejunoileal perforations are difficult to identify by CT. In our series, free intraperitoneal air, as a direct finding of perforation, was observed in 33% of cases, while free intraperitoneal fluid, as an indirect diagnostic finding, was the most frequent sign.

Abstract: Aim of this study was to assess the role of Computed Tomography (CT) in the management of acute laryngeal injuries by reviewing our 5 years' experience. From January, 1991, to November, 1996, sixteen patients with blunt trauma and 2 patients with penetrating injuries of the larynx underwent physical examination, laryngoscopy and CT; 2 of them underwent angiography too. The patients were divided into 3 groups according to Schaefer classification [13], first on the basis of physical examination, CT and laryngoscopy findings. The definitive group and therapy were decided on the basis of final spatial assessment. Physical examination diagnosed the presence and the anatomical level of laryngeal injuries in group I (4 patients); laryngoscopy and CT depicted the type of injury and suggested conservative management in 100% of cases. In group II (10 patients), conservative management was suggested by CT findings in the laryngeal, submucosal soft tissues and fascial plane injuries in 100% of cases. Physical examination findings were correct in 30% of cases, questionable in 30% and incorrect in 30%; the exam was not performed in 10% of cases. Finally, laryngoscopy findings were correct in 60% of cases, incorrect in 20% and not diagnostic in 20%. In group III (2 patients), exposed laryngeal injuries required immediate surgery. In group II, the selective application of CT was useful for assessing the degree of damage in 100% of cases and was helpful in planning conservative management. CT avoided surgery in one patient, showed laryngeal cartilaginous features in 2 patients and 2 pseudoaneurysmal injuries not suspected on the basis of physical examination findings.

Abstract: Ischemic bowel disease is a rare disorder whose incidence is increasing as the mean age of the population increases. Diagnosis by clinical, laboratory and radiologic means is often difficult, and delay in definitive therapy results in substantial morbidity and mortality. A series of 26 consecutive patients, with proved acute superior mesenteric ischemia, was retrospectively reviewed: the authors report the diagnostic methods performed preoperatively, the site and the cause of infarction and the time passed between the first radiograph ans surgery. Plain abdominal radiographs were performed in 25 of 26 patients, screening abdominal US in 23 cases and CT in 19 cases. All radiological examinations were retrospectively reviewed by three authors, independently, to recognize the different signs of infarction. On plain abdominal films, the findings warranting a presumptive diagnosis of bowel infarction were air-fluid levels (84% of cases), dilated bowel loops (48%), thickened and unchanging loops (20%), gastric distension and gasless abdomen (12%), small bowel pseudo-obstruction (8%). Screening abdominal US demonstrated intraperitoneal free fluid (26%) and dilated bowel loops (22%). Abdominal CT showed air-fluid levels (79%), dilated loops and free intraperitoneal fluid (47%), intramural gas and thickened bowel loops (36.8%), engorgement of the mesenteric vessels (31%), mesenteric-portal gas, mesenteric thrombus and marked reduction in the volume of gas in the small bowel (10.5%) and paper-thin bowel loops (5%). The authors conclude that air-fluid levels, dilated loops and intraperitoneal free fluid are the most frequent findings, even though they are not specific. While abdominal plain film and screening ultrasonography can be negative, CT detects at least one abnormal finding and at least three abnormal findings in 73% of cases.

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.

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Abstract: INTRODUCTION: Laryngeal mucosal perforation is a frequent event whose diagnosis is based on clinical, laryngoscopic and CT findings. MATERIAL AND METHODS: We reviewed retrospectively the data relative to 77 patients with blunt neck trauma examined October, 1991, to June, 1996. All patients were submitted to clinical examination first and then, to fiberoptic laryngoscopy and CT on the clinician's request. RESULTS: Nineteen patients with small skin tears and no signs and symptoms of laryngeal injury were immediately discharged while 37 patients were submitted to surgery: 17 to remove cerebral hematomas, 13 to stabilize cervical fractures and 7 because of hemodynamic instability. Twenty-one patients underwent laryngoscopy which showed laryngeal lesions in 12: wide mucosal disruption with fractures of the laryngeal skeleton and hematomas were observed, which needed immediate surgery with airway reconstruction in 7 cases; small mucosal tears and hematomas were seen and laryngeal CT examination was requested to establish the possibility of conservative management in 5 cases which are the subject of the present study. Laryngoscopic findings were: 1) laryngeal mucosal tear near the thyroid cartilage with quadrangular membrane edema, 2) thyroid mucosal tear with thyrohyoid muscle edema, 3) edema of the left false vocal cord, 4) edema of the oblique arytenoid muscle, 5) posterior cricothyroid muscle edema with bleeding near the cricoid ring. In cases 1, 2 and 3 CT showed gas bubbles in the paralaryngeal space, where laryngeal tear or edema were indicated at laryngoscopy. DISCUSSION: CT does show the "gas bubbles" in the paralaryngeal space when laryngoscopy cannot distinguish laryngeal mucosal perforation from tear. CONCLUSIONS: The routine use of CT in minor, laryngeal injuries in the emergency department is useful for the early diagnosis of laryngeal mucosal perforation.

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Abstract: The authors report on 16 healthy volunteers examined with anal endosonography. The US examinations were performed with a dedicated Bruel and Kjaer 1846 unit equipped with a 7-MHz probe (type 1850) with 360 degrees circular mechanic movement. A rigid plastic cone filled of degassed water is mounted on the probe to ensure the symmetrical representation of the anal canal. A condom with gel on both the internal and the external surfaces is put on the cone. The peculiar anatomy of the single layers which form the anal canal determines their different US patterns. Endosonography was performed on three levels, i.e., deep, intermediate and superficial planes. In the deep plane (at the anorectal junction) anal endosonography demonstrates: epithelial-subepithelial complex (intermediate echogenicity); internal sphincter muscle (low echogenicity), made of smooth muscular fibers; longitudinal muscle (intermediate echogenicity), made of smooth and striated muscular fibers; puborectal muscle (high echogenicity), made of striated muscular fibers, and perineal body, which has a longitudinal shape in men and a transverse shape in women. In the intermediate plane anal endosonography demonstrates: epithelial-subepithelial complex, internal sphincter muscle, longitudinal muscle, and external sphincter muscle (high echogenicity), made of striated muscular fibers. In the superficial plane (distal anal canal extremity), anal endosonography demonstrates: epithelial-subepithelial complex and external sphincter muscle. Internal sphincter muscle thickness was measured and the results follow: while the average thickness was 2.1 mm, we had 1.8 mm in 12 patients under 44 and 2.6 mm in 4 patients over 44 years old. This finding is in agreement with literature data. External sphincter muscle thickness did not vary significantly in the two groups.

Abstract: Two different series of patients with burst injuries of the hand were retrospectively reviewed: one series included 23 men, 15-55 years old, referred to the emergency department for the first-instance assessment of injuries of the right hand (13 patients) and left hand (10 patients). The other series included 44 patients (42 men and 2 women, aged 7-61 years) referred to our department for second-instance examinations: the latter patients had burst injuries involving only the hands in 43 cases and both the hand and the foot in one case. We report the radiologic patterns of traumatic bone injuries (fractures and amputations) and of musculotendinous and cutaneous injuries and discuss their mechanisms and pathogenesis. The two series were compared and the results follow: in both series the right hand was more frequently involved, metacarpal bones were most often fractured and phalanges most often amputated. In the first series, in the right hand the carpal bones were involved in one patient only, the 2nd and 3rd metacarpal bones were most frequently fractured and the 2nd finger was most frequently involved. In the left hand, the carpal bones were never affected, the 1st metacarpal bone was most often amputated and the 5th metacarpal bone most often fractured; the 2nd finger was most frequently involved. In the second series, in the right hand, the 1st metacarpal bone was most frequently fractured and the 2nd metacarpal bone most often amputated; the 2nd finger was most frequently involved. In the left hand, the 4th metacarpal bone was most frequently fractured and the 5th metacarpal bone most often amputated. The severity of the above injuries and the extent of tissue damage depend on several factors, including firecracker speed, shape, size, weight and characteristics. Radiologic exams are very useful for the accurate study of these traumatic injuries, providing indirect information about musculotendinous and cutaneous involvement. Prompted by the relative lack of information on the management of these injuries, we suggest that radiologic exams be quickly performed to help choose the most appropriate surgical approach for best cosmetic and functional results.

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Abstract: A survey was made in 13 Italian centers with a questionnaire concerning the (a) indications, (b) postoperative complications, (c) functional results and (d) diagnostic imaging modalities related to the making of an ileal or colonic (neo) rectum. Ulcerative colitis (100%), familial polyposis (61.5%) and Crohn's disease (15.3%) were the most common indications for an ileal pouch; rectal cancer (7.96%), chronic inflammatory diseases (15.3%), diverticulosis, rectal prolapse, redundant colon and imperforate anus (7.6% each) were the most common indications for a colonic pouch. Postoperative complications included pelvic abscess (14%), sinus tract/dehiscence (10%) and bowel obstruction (9%). When compared with the S and W variants, the J-shaped ileoanal pouch proved superior because urgency and fecal retention rates were lower (18.4% vs. 44.4% and 23% vs. 28.6%, p < 0.01 and p < 0.05, respectively), despite slightly more frequent staining episodes (15.8% vs. 11.1%; p < 0.05). As for colonic ampullae, fecal retention and provoked evacuation were more frequent in the J pouch and after gracileplasty; urgency and incontinence in the straight colo-anal anastomosis (33.3% vs. 22.2% and 41.6% vs. 33.3%, respectively). The functional outcome was assessed by anal endosonography (available in 4/13 centers), defecography and anorectal manometry. Abnormal findings included: (a) reduced capacity, barium leakage, anal gaping, sphincter damage (urgency and incontinence); (b) barium retention, pouch dilatation, split evacuation, knobs and strictures (fecal retention).

Abstract: Plain abdominal radiography is the method of choice to diagnose gastrointestinal perforation because it shows the presence of free intraperitoneal air and of other associated radiologic signs. Recently, the modern methods of cross-section imaging, that is US and CT, have become useful tools for the accurate detection and depiction of free abdominal air, especially when plain films are normal or nonspecific. A series of 61 consecutive patients operated on for viscus perforation at Cardarelli Hospital, Neaples, was retrospectively reviewed: the authors report the site and cause of perforation and the diagnostic methods used preoperatively to recognize the radiographic sign of free air; examination time and the time passed between the first radiograph and surgery were also investigated. Of 61 patients, 53 underwent preoperative radiologic exams: plain abdominal radiographs were performed on 50 patients, abdominal US on 29 and CT on 15, while 8 patients were submitted to surgery with no previous diagnostic examination. Direct and indirect signs of perforation were assessed to compare the sensitivity of the methods and to suggest a possible diagnostic protocol. Combined radiography, US and CT showed signs of perforation in 71% of cases (direct signs in 57.5% and indirect signs, that is free intraperitoneal fluid and hypoperistalsis, in 14.5% of cases). When free air was absent (1/3 of cases), free intraperitoneal fluid was the only radiologic finding. The authors conclude that plain abdominal radiography, when correctly performed, is still the main tool permitting free air, if present, to be depicted in 100% of cases. When plain abdominal radiography is positive, other radiologic procedures are unnecessary while, when it is negative and symptoms persist, US and CT should be performed after at least 6 hours' interval to allow the radiologic picture to change markedly.

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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: Anal endosonography (US) is a valuable tool to represent the normal anatomy of the anal canal and also to reliably examine patients with anal conditions. Our series consisted of 40 patients with suspected inflammatory and traumatic conditions of the anal canal submitted to anal US, which showed the presence of abscesses in 18 patients with suspected anal canal inflammation. A fistula was associated in 14 of the 18 patients and US after air injection easily showed a cutaneous orificium in 6 of the 14 patients. Anal US showed the presence and site of all abscessual foci and fistulae, also identifying the inner orificium and the involvement of muscular sphincteral structures, which is useful information to plan the most appropriate medical or surgical treatment. As for traumas, anal US is also a useful tool for identifying sphincteral injuries secondary to blunt trauma and for following-up sphincteral reconstruction with graciloplasty. Twenty-two patients with suspected sphincteric trauma were examined and anal US showed a sphincteral injury in 7 of 13 patients with acute postpartum-related symptoms; the clinical picture was ascribed to postpartum stretching of the pudendal nerve in 6 other patients. Finally, this method can be very useful in the follow-up of anal diseases, both to study surgical drainages and in the postoperative study of anal fistulae.

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: We report a preliminary experience concerning the postoperative assessment of three patients who underwent gracilis neosphincter operation for severe fecal incontinence and were studied by computed tomography and anal endosonography soon after gracilis transposition and later after 6-8 weeks of neuromuscular training. Morphologic assessment was correlated with physiologic testing (manometry). Continence was satisfactorily improved in all patients. Both imaging techniques demonstrated the anatomy of the transposed muscle. Computed tomography also assessed lead placement onto the gracilis nerve root and the completeness of muscle transposition around the anal canal. Anal endosonography provided a more accurate assessment of the relation between the neosphincter and residual external sphincter.

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 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: 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: It is known that an acute postemetic injury may evoke a spontaneous rupture of the oesophagus. This spontaneous rupture may produce an intramural hematoma or a laceration of the oesophagus wall. The intramural hematoma is restricted to the esophageal wall and may produce a fistula into the lumen of the oesophagus (with creation of a double lumen) or into the mediastinum (haematoma of the mediastinum). On the other hand the rupture may extend from the mucosa (lesion of Mallory-Weiss) into the complete wall of the oesophagus (Boerhaave's Syndrome). There are reports on a lesion of the exterior muscular layer of the third distal half of the oesophagus, which had evoked an acute haemorrhage into the mediastinum and has been defined as a variant of Boerhaave's syndrome. We now describe a similar case which is confined to the cervical oesophagus and has been treated without surgical intervention.

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.

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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: The nonoperative treatment--i.e., rubber band ligation and sclerotherapy--of mucous rectal prolapse, rectocele and intussusception is much less expensive than conventional surgery (Lit. 325,000 vs. 6,500,000, p < 0.0001 on the average). Symptom relief, however, has been reported in 0 to 57% of cases only, according to current literature. A possible cause is represented by improper management from misdiagnosis, relying on clinical findings only, overestimating mucous prolapse in 36.37% of cases and underestimating intussusception in 14.22% of cases (with respect to defecography). Defecography is a cost-effective method (average cost: Lit. 37,000) potentially reducing failure rate after the surgical repair of rectal prolapse.

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: Impaired intestinal function, negatively affecting food digestion and absorption, is called chronic intestinal failure (CIF). The clinical conditions leading to CIF are: fistulas, wide resections and severe damage to small bowel, and chronic intestinal stasis. In the etiology of CIF, the most frequent conditions are: Crohn's disease, postoperative peptic ulcer, mesenteric arteriopathy, radiation enteropathy, acute pancreatitis, jejunoileal diverticulosis and intestinal pseudo-obstruction. The radiologic approach to CIF can aim at: 1) diagnosing the disease and the clinical conditions causing it; 2) morphometric analysis: lesion spread, length of the extant normal small bowel and adaptive changes. Digestive tube radiology has always been considered a fundamental investigation technique to study malabsorption. Double contrast enema has increased the diagnostic capabilities of radiology. Moreover, double contrast enema allows the extraoperative evaluation, in vivo, of a new anatomic feature--i.e., intestinal length--which is a valuable sign for an exhaustive interpretation of CIF, especially of the short bowel syndrome. Thanks to double contrast enema, the changes in the length of mesenteric small bowel can be calculated in vivo (range: 150-430 cm; mean: 291 cm, SD 59). Intestinal length < 150 cm was observed only in resected patients. In 25% of cases, short small bowels were associated with CIF. Such morphometric studies, if applied to clinical practice, may yield valuable information for both diagnosis and prognosis.

Abstract: We have identified 18 cases of functional pouch of the posterior rectal wall visualized by defecography. In the absence of previous evidence in the literature, we named this anomaly "posterior rectocele" and studied it from the clinical, radiologic, and endoscopic points of view.

Abstract: A questionnaire concerning defecography was submitted to 5 national experts in order to: 1) quantify the demand and 2) develop a consensus report. The demand is currently 2-8 exams week and the most frequent indication (70%) is obstructed defection, with/without constipation. The highest discriminatory capabilities was exhibited by the following variables: a) the anorectal angle (ARA) on straining and b) the distance from the pubococcygeal line (PCL) on squeezing (101.2 degrees +/- 15 vs. 120.6 degrees +/- 13, p < 0.05 and 27.4 mm +/- 15 vs. 2.4 mm +/- 7, p = 0.005, respectively) in chronically constipated patients (mean age: 60 years) when compared to the control group; and c) PCL on squeezing and at rest (35.5 mm +/- 20 vs. 2.4 mm +/- 7, p = 0.005 and 38.9 mm +/- 18 vs 18.4 mm +/- 17, p < 0.05, respectively) in patients with severe incontinence with respect to healthy subjects. While sensitivity and positive predictive values of the test were highest (97 and 98% respectively) for rectocele, specificity ranked first (92%) in anal gaping.

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.

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Abstract: The authors report eight cases of rectocele in male subjects studied with defecography and computed tomography. The pocket is located between the prostatic apex and the urogenital diaphragm. The abnormality has clinical significance.

Abstract: The authors describe the results of their series of 260 fine (22G) needle aspiration biopsies (FNAB) of thoracic and abdominal lesions. Diagnostic accuracy, technique, eventual complications are valued. They recommend that this diagnostic procedure is performed with 22G needle and scrupulous technique; the FNAB, if so carried out, is a sure, quick and high accurate tool to characterize uncertain lesions, avoiding explorative surgery.

Abstract: The inhibitory effect on platelet function induced by several radiographic contrast media is still poorly understood. In this study platelet abnormalities caused by in vitro addition of ioglicinic acid, a new ionic contrast medium, were evaluated. The appearance of several granules similar to dense bodies associated with shape change and internal reorganization were detected by electron microscopy techniques. A functional study revealed a marked decrease in the aggregating response of platelets to adenosine diphosphate and calcium ionophore A23187, while aggregation in response to collagen was completely normal. It is suggested that ioglicinic acid induces platelet abnormalities related to the effect on calcium movements and that studies with this contrast medium may help the understanding of some basic events of platelet activation.

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Abstract: The ability of intrarectal ultrasound to recognize the local extent of disease was investigated in 23 patients with histologically proven adenocarcinoma of the lower two-thirds of the rectum before operation. Two probes, 12 cm long, working at a frequency of 3.5 and 7.5 MHz, were used. The results were compared with those of pre-operative computed tomography (CT) and with the pathological report of the resected specimens. Sonography correctly staged 20 of 23 tumours with two false negatives and one false positive, while CT correctly staged 19 of 23 tumours with two false negatives and two false positives. The results of ultrasound were found to be as accurate as those of CT; the low cost and simple use of ultrasound makes it preferable in the pre-operative assessment of the depth of invasion of rectal cancer. In addition, intrarectal ultrasound was routinely performed in 42 patients, operated on for rectal cancer by means of sphincter-saving procedures, at variable intervals in the first 2 years postoperatively. Eight local recurrences were recognized and confirmed by CT. Based on the low cost, reliability and simple use, intrarectal ultrasound is proposed as first examination for local recurrence detection in the follow-up of patients with low anterior resection for rectal cancer.