Objectives

Assessment of pattern of arterial involvement in carcinoma gall bladder with MDCT Angiography.

Background

Gallbladder cancer is the most common malignancy of the biliary tract, representing 80%–95% of biliary tract cancers worldwide, according to autopsy studies. It ranks sixth among gastrointestinal cancers . MDCT has a reported accuracy of up to 84% in determining local extent or the T stage of primary gallbladder carcinoma and 85% in predicting resectability through its ability to delineate hepatic and vascular invasion, lymphadenopathy, and distant metastases.

With it's increasing use and availability,preoperative MDCT angiography helps not only for staging of the disease but also acts as a roadmap for the assessment for arterial involvement.To our knowledge ,this is one of the few studies depicting the pattern of arterial involvement in gallbladder cancer.

Imaging findings OR Procedure findings

All CT examinations were performed on a 64- MDCT scanner (Philips Medical System Version 6.4, Extended Brilliance Workspace ).Triphasic Angiography was performed after the IV administration of nonionic contrast material {Iodixanol(visipaque)};volumes varied between 100 and 150 mL at 1.5 ml/Kg.After injection of intravenous contrast material, liver was scanned in arterial (scanning delay, 20-30 seconds), portal (scanning delay, 60-70 seconds), and equilibrium (scanning delay, at 3 minutes) phases

Conclusion

Half of the cases (43.5%) of carcinoma gall bladder showed arterial involvement at the time of diagnosis; most commonly involved artery was found to be cholecystic artery followed by right hepatic artery and replaced right hepatic artery.

Objectives

Our purpose is to present clinical symptoms and imaging findings of a scarce vascular syndrome mimicking chronic mesenteric ischemia, often in need for surgical treatment.

Background

Median arcuate ligament syndrome, also known as celiac artery compression syndrome, is a rare entity often misdiagnosed. Classic symptoms include postprandial abdominal pain, weight loss, nausea and vomiting. Due to its clinical presentation mimicking other conditions such as peptic ulcer, gallbladder disease, appendicitis and mesenteric ischemia, patients suffering from this disease usually undergo multiple radiological and gastroenterological examinations before they get their final diagnosis by Computed Tomography Angiography (CTA). We present 2 such patients who came to our Computed Tomography Department in order to investigate the aforementioned symptomatology by undergoing a CTA examination.

Imaging findings OR Procedure findings

In both patients there was absence of celiac artery atherosclerosis, whereas focal narrowing of the superior aspect of the proximal celiac trunk and post-stenotic dilatation existed (‘the classic hooking configuration of the proximal celiac trunk’). In one of the patients, proximal superior mesenteric artery compression coexisted. There also was thickening of the median arcuate ligament in both cases (5.7mm and 8mm respectively).

Conclusion

CTA is considered to be the gold-standard imaging examination for the detection of celiac artery compression syndrome. It easily presents the proximal celiac stenosis with classic hooking configuration, post-stenotic dilatation or collateral formation and thickness of the median arcuate ligament of more than 4 mm. Symptomatic patients should be surgically treated by dividing the median arcuate ligament, usually laparoscopically.

Objectives

To review the main aspects of the aortic repair, how to identify the principal different grafts and surgical techniques (open and endovascular) and recognize some common and uncommon complications and it mimickers.

Background

Aortic aneurysm is an abnormal dilatation of the aorta, carrying a substantial risk of rupture and thereby marked risk of death. The complication depends on patient vascular anatomy, extension and type of aneurysm, as can be related to procedure specific techniques.

Imaging findings OR Procedure findings

The uncomplicated aortic post operatory, showing how to differentiate between open surgical procedure and endovascular aneurysm repair (EVAR).

Differences on EVAR devices, with 3D reformation and schematic illustrations.

Analyzing some surgical complications, such as endoleak, infection, stent / coil migration, aneurysmal growth, pseudoaneurysm, signs of vulnerability and risk of rupture, fistulas and collections, occlusion / stenosis, aortic dissection, organ ischemia and other endovascular procedure specific complications.

Conclusion

Aortic aneurysms are a common vascular affection with a myriad of possible surgical treatments and outcomes. The importance of recognition of normal post operatory aspects and its complications relies on prognosis of the patient, implying on possible change of medical decision.

Objectives

1. Demonstrate the decisive role of endovascular techniques in the treatment of nonvariceal upper gastrointestinal (UGI) bleeding.

2. Describe an educational guide for TAE, outlining the indications, techniques, complications and limitations.

Background

UGI hemorrhage is a major cause of morbidity and mortality despite numerous advances in diagnosis and treatment. The most common cause of UGI bleeding is peptic ulcer disease, but multiple etiologies must be taken into account. Aggressive treatment with early endoscopic hemostasis is essential for a favorable outcome. However, in some cases, surgical intervention may eventually become necessary, but it can be associated with high mortality rates. Endovascular management has emerged as an alternative to operative intervention for high-risk patients and is now considered the first-line therapy for massive UGI bleeding refractory to endoscopic.

Imaging findings OR Procedure findings

TAE is an effective and minimally invasive procedure, because of the diversified arteriographic manifestations of acute UGI haemorrhage and the proper selection of embolic agents. Selective catheterization of the artery thought to most likely supply the site of bleeding should be performed first. For UGI bleeding, this would be the celiac artery followed by the superior mesenteric artery. After locating the source of bleeding, appropriate embolic agents, such as coils or microcoils, gelatin sponge, PVA, gelatin particles etc., are used to embolize the targeted vessels.

Conclusion

Massive bleeding from the upper tract remains a challenge. The safety and efficacy of TAE for the treatment of life-threatening nonvariceal UGI bleeding is now widely accepted and is considered the gold standard for endoscopy-refractory patients.

Objectives

To familiarize readers with MDCT findings of some uncommon conditions presenting with acute abdomen.

Background

Acute abdomen is a common emergency presentation. Most patients undergo MDCT scans. While radiologists are familiar with the myriad common conditions presenting with acute abdomen, some less commonly encountered conditions may also be seen. Knowledge of these conditions and their imaging findings is imperative for accurate diagnosis and appropriate management.

Imaging findings OR Procedure findings

- Thrombophlebitis of portal-mesenteric venous system. It commonly occurs as a complication of intra-abdominal infections (e.g. diverticulitis or ileitis/colitis). CT demonstrates inflammation of and filling defects within portal-mesenteric veins and source of infection. Perfusion alterations in the liver may also be seen and need to be differentiated from abscesses.

- Retroperitoneal fasciitis. A rapidly progressive infection involving retroperitoneal soft tissues, often ascending from lower extremity. CT features include retroperitoneal fascial thickening, fat stranding, fluid and abscess and rarely, retroperitoneal gas.

- Spontaneous isolated visceral artery dissection. Occurs spontaneously, most often in males in the fifth decade. CT findings include intra-arterial dissection flap or eccentric mural thrombus. Periarterial fat stranding and end organ ischaemia may also be seen.

- Torsion of fatty appendage of falciform ligament. Presents with acute epigastric pain. CT findings include an area of fat attenuation with hyperattenuating rim and surrounding inflammatory stranding along the falciform ligament. There may be central hyperattenuation due to venous thrombosis.

Conclusion

We present MDCT findings of uncommon conditions presenting with acute abdomen, which are important for radiologists to be familiar with so as to ensure timely and appropriate management.

Objectives

The purpose of the present study was to evaluate the computed tomography findings of postpartum hemorrhage and discuss relevant anatomical findings and possible mechanism(s).

Background

Postpartum hemorrhage (PPH) is an obstetric emergency that can follow vaginal or cesarean delivery. Even though computed tomography (CT) is not presently an appropriate first-line diagnostic procedure for the evaluation of PPH, it can provide information leading to its detection, localization, and characterization in certain challenging cases. Further, contrast CT can accurately identify the anatomic location of significant arterial hemorrhage based on the extravasation of intravenous contrast material; this will help guide treatment planning and execution.

The findings of this study provide important knowledge regarding the various radiologic appearances of PPH and their correlation with clinical information.

Imaging findings OR Procedure findings

Normal anatomy of the reproductive organs in women with illustrations

Radiologists require an extensive anatomical knowledge of the reproductive organs, supplying vessels, and supporting ligaments in women for the accurate diagnosis of PPH.

Imaging findings of emergency PPH

●Uterine atony: the lack of effective uterine contractions after delivery

●Retained placenta: the lack of placental expulsion within 30 minutes after delivery of the infant

● Puerperal genital hematoma: resulting from episiotomy trauma or birth canal trauma

● Uterine rupture: the most common cause is tearing along a previous cesarean hysterectomy scar

Conclusion

The knowledge of the various radiological appearances of PPH and their correlation with clinical information can ensure accurate diagnosis and appropriate treatment planning in the patients with PPH.

Objectives

Intestinal obstructive conditions are frequent causes of acute abdomen and sometimes their diagnostic can be challenging for the emergency radiologist.

Through several cases of intestinal obstruction with different causes, evaluated by computed tomography, we propose a systematic analysis aiming to increase the diagnostic accuracy.

Background

Sometimes, intestinal suboclusion can be managed conservatively, as in case of adhesions. However, some cases have higher morbidity and mortality, because they may be associated with ischemia and bowel perforation, constituting surgical urgencies, as in cases of volvulus and internal hernias.

The radiologist plays a fundamental role in the therapeutic decision and must be as assertive as possible.

Imaging findings OR Procedure findings

Intestinal obstruction/subocclusion is defined as dilatation of bowel loops larger than 2.5 - 3.0 cm, with distal loops of normal/reduced caliber, features there are easily detected in a fast evaluation of abdominal CT. However, identifying its cause, which is an important prognostic factor, and essential for proper management, is sometimes a complicated and difficult process that requires time and attention from the radiologist.

Multidetector computed tomography (CT) is the best diagnostic method for obstructive acute abdomen and its complications, mainly with intravenous iodine contrast.

Multiplanar and oblique reconstructions are a important tool for bowel obstruction evaluation and surgical planning. We recommend that radiologists use this resource in all patients, as part of the routine evaluation.

Conclusion

The determination of a systematic bowel assessment routine helps the radiologist to diagnosis bowel obstruction and increases the ability to identify its probable cause.

Objectives

Petersen's hernia is a form of internal hernia that can occur following any form of gastojejunostomy surgery.

The presentation of diffuse abdominal pain and potential obstruction is non specific, therefore the role of imaging is key to early diagnosis, allowing prompt surgical intervention.

We present 3 cases. Given the diagnostic importance of imaging, the learning objectives are twofold : Firstly to highlight this uncommon but serious complication, and its common precipitating factors and secondly to provide a concise illustrative reference to aid recognition and detection of this pathology.

Background

Petersen's hernia can occur in the potential posterior space created between the limbs of small bowel, the transverse mesocolon and the retroperitoneum, following any form of gastojejunostomy surgery.

A laproscopic surgical approach, with resultant lack of adhesions, increases the post operative risk of internal hernia. In addition, pregnancy and weight loss are other recognised risk factors for internal hernia occurrence.

Imaging findings OR Procedure findings

We present 3 cases of surgically confirmed Petersen's hernia that presented with increasing abdominal pain and tenderness, who demonstrated classic imaging features of:

Proximal small bowel obstruction

Swirling of the mesenteric vessels

Previous gastrectomy surgery

One case shows evidence of recent emergency caesarean section, highlighting a common predisposing factor.

Conclusion

Petersen's hernia is an uncommon but important complication following gastrectomy. Presenting signs and symptoms are non specific, imaging thus plays a vital role in early diagnosis allowing prompt surgical management.

These cases highlight both important predisposing factors and classic imaging findings to aid the general radiologist in making an accurate and timely diagnosis.

Objectives

- Review the microbiology, pathogenesis and clinical manifestations of actinomycosis.

- Recognize the imaging characteristics of abdominal actinomycosis.

- Understand the different presentations of abdominal actinomycosis and the important role radiology plays in diagnosis.

Background

Actinomycosis is a rare chronic suppurative bacterial infection caused by Actinomyces Israelii. 20% of the patients with actinomycosis present with abdominopelvic symptoms.

Clinical presentation is non-specific and mimics neoplastic symptoms. Abdominal actinomycosis is understood to occur after the disruption of the intestinal mucosal integrity caused by appendicitis, colonic diverticulitis, penetrating trauma, or surgery. Given the non-specific signs and symptoms differential diagnoses include invasive malignancy or inflammatory processes.

Imaging findings OR Procedure findings

Abdominal actinomycosis is a difficult diagnosis to make on imaging alone and can remain undetected for months to years due to its indolent nature and nonspecific symptoms.

Common CT findings are concentric bowel wall thickening accompanied by a cystic or solid mass in the vicinity of the affected bowel segment surrounded by prominent inflammatory infiltrations. Solid portions of the mass and the surrounding soft-tissue infiltrates demonstrate dense contrast enhancement. The aggressive nature of the infiltration is a diagnostic clue for actinomycosis.

The invasive nature of the mass often is suggestive of a neoplasm, however regional lymphadenopathy is rarely associated. Despite the unrestricted infiltrative nature of abdominal actinomycosis, it is unlikely to spread into the entire peritoneal cavity. Ascites is usually minimal or absent.

Conclusion

Abdominal actinomycosis involves many organs and it mimics cancer. Awareness of its imaging findings will aid with the differential diagnosis of abdominal masses.

Objectives

Identify radiological signs related to subtle pancreatic trauma and concurrent extra-pancreatic findings associated with the mechanism of injury.

Accurately describe the relevant injury in the radiology report to guide further imaging/ management.

Review relevant management issues as applicable to the radiologist including imaging guided intervention.

Evaluate the role of further imaging including MRCP/ MR & ERCP.

Background

Pancreatic injuries are uncommon however, early recognition is important as they are associated with significant morbidity and mortality. Most injuries are secondary to blunt trauma for example, impact to the upper abdomen on the steering wheel in a road traffic accident. Pancreatic trauma is difficult to recognise given the often subtle imaging findings and distracting coexisting injuries to other abdominal organs.

Imaging findings OR Procedure findings

Early imaging findings in pancreatic trauma are often subtle including fluid surrounding the superior mesenteric artery/vein “cuff sign”, left anterior pararenal fascia thickening, peripancreatic fat stranding and fluid in the transverse mesocolon or lesser sac.

Assessment of pancreatic duct integrity is important as it informs the decision as to whether the patient requires surgery. The anatomic location of the contusion, laceration or fracture also aids in the assessment of the severity of the injury, with proximal injuries associated with a worse prognosis.

There is a high probability of developing a complication following pancreatic trauma. Complications include pancreatitis, haemorrhage, pseudocyst and fistula formation.

Conclusion

We will systematically illustrate imaging features of pancreatic trauma, present associated complications and discuss the role of further imaging/ image guided intervention.

Objectives

To present the spectrum of Meckel’s diverticulum complications in non-pediatric patients and to discuss the role of MDCT in the diagnosis of this rare emergency condition.

Background

Meckel’s diverticulum is the commonest congenital anomaly of the gastrointestinal tract [2% of the population]. It is usually asymptomatic with a 4.2–6.4% lifetime risk of complication. Symptoms depend on the complication, and include rectal bleeding due to intestinal hemorrhage, abdominal pain, vomiting and distension resulting from obstruction and pain with fever due to diverticulitis. The diagnosis is often challenging with imaging playing the key role for the recognition of this rare entity and its differentiation from other common abdominal emergencies.

Imaging findings OR Procedure findings

Meckel’s diverticulum usually appears at MDCT scan as an abnormal outpouching, blind-ending fluid or gas-filled structure connected to the terminal ileum. An inflamed Meckel’s diverticulum shows wall enhancement and mesenteric fat stranding. Fluid collections or a frank abscess may also be present. In case of bowel obstruction, a Meckel’s diverticulum can be found at the site of the transition zone, occasionally with enteroliths within the lumen. Mesenteric fat stranding or an abscess may also be seen in case of inflammation. Meckel’s diverticulum may also act as a lead point for intussusception, resulting to bowel obstruction. Active extravasation of contrast from Meckel’s diverticulum, can be found in case of hemorrhage, along with perforation or hematoma.

Conclusion

MDCT findings of complicated Meckel’s diverticulum are variable, and radiologists should be aware of them, in the evaluation of patients with acute abdomen.

Objectives

To describe the usefulness of DE-CT in the abdominal trauma.

Background

Abdominal traumatic injuries represent an emergency condition with high mortality, so the prompt evaluation and the correct therapeutic planning are crucial. The CT has become the standard of care for hemodynamically stable patients and the DE- CT could give a great aid, thanks to the variety of post-processing applications.

Imaging findings OR Procedure findings

The identification of parenchymal organs injuries, which appear as hypo-attenuated geographic area, can be challenging in the evaluation of degree and severity of the lesions, particularly in case of not severe damage: DE-CT with low-kilovolt peak and low-kiloelectron volt images improve their visualization. The iodine-selective imaging helps in distinguishing the parenchymal hematomas from organ laceration. Regarding the evaluation of bowel traumatic injuries, iodine-selective and virtual monoenergetic imaging could improve the visibility of altered bowel wall enhancement. Another application of DE-CT could be represented by the study of any vascular injuries: low-kiloelectron volt monoenergetic images and the combined analysis of virtual noncontrast (VNC) and iodine-selective images make ease the identification of active extravasation, also when there are fracture fragments. The VNC images help in the detection of parenchymal, intramural vascular and bowel hematomas.

Conclusion

In the literature, even if there are only few articles about DE-CT application in abdominal trauma and this technique could have pitfalls and artifacts that radiologist must be aware, it seems to be a promising and valuable potential in detecting and better define the injuries.