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

1. To review the clinical presentations and pathophysiology of Meckel’s diverticulum.

2. To become familiar with the broad radiological spectrum in the different imaging techniques, especially enteroclysis, of Meckel's diverticulum.

Background

Meckel diverticulum is the most common congenital anomaly of the gastrointestinal tract, occurring in 2%–3% of the population. It results from improper closure and absorption of the omphalomesenteric duct. Most (75%) Meckel’s diverticula are found within 100 cm of the ileocecal valve. Heterotopic gastric and pancreatic mucosa are frequently found histologically within the diverticula of symptomatic patients. The most common complications are hemorrhage from peptic ulceration, small intestinal obstruction, and diverticulitis.

Imaging findings OR Procedure findings

Enteroclysis is the best way to diagnose Meckel diverticulum. It is identified as a saccular, blind-ending structure located on the antimesenteric border of the ileum. The antimesenteric location can be confirmed from the position of the diverticulum, which faces away from the axis of the root of the small intestinal mesentery. The junction of the diverticulum with the ileum may show a mucosal triangular plateau or triradiate fold pattern, which represents the site of omphalomesenteric duct attachment to the ileum. Filling defects within the diverticulum may represent enteroliths, fecoliths, or foreign bodies. On CT Meckel’s diverticulum is difficult to distinguish from normal small bowel in uncomplicated cases. However, a blind-ending fluid or gas-filled structure in continuity with small bowel may be seen.

Conclusion

While CT findings may be helpful to suspect the presence of Meckel diverticulum, enteroclysis is the procedure of choice to confirm the diagnosis.

Objectives

To study imaging findings of Contrast Enhanced Ultrasound (CEUS) for detecting infarcts of the liver, spleen and kidneys. To describe the technique for performing a CEUS examination. To compare CEUS findings to baseline US images. To explain CEUS advantages relating to diagnostic performance, feasibility, short examination time and low cost.

Background

Infarcts are often seen in the liver, spleen and kidneys. Baseline unenhanced US may overlook them, as they can be ill-defined or isoechoic to the rest of the organ’s parenchyma. As in CT and MR, the addition of contrast agents in US improves diagnostic performance and lesions that can be overlooked before the injection of the contrast agent can be identified on CEUS.

Imaging findings OR Procedure findings

We review underlying pathophysiology for the formation of infarcts in the liver, spleen and kidneys. We explain imaging findings on US before and after the administration of the contrast agent. We present cases of hepatic, splenic and renal infarcts, with findings on baseline US and CEUS. We compare images of baseline US to CEUS in order to show the value of contrast injection for setting a diagnosis or confirming baseline US findings. We compare CEUS findings to CT or MR when these were performed.

Conclusion

CEUS improves the detection and delineation of abdominal solid organ infarcts and lesions overlooked on baseline scanning are readily observed after contrast injection. The examination is quick, safe and easy to perform. In all cases with infarct suspicion, CEUS should be performed on a routine basis.

Purpose

To assess the diagnostic value of contrast enhanced ultrasound (CEUS) for follow up of hospitalised patients who suffered solid abdominal organ trauma after initial imaging with contrast enhanced computed tomography (CECT). To compare CEUS follow up imaging findings to those of the first CECT.

Material and methods

63 patients (37 men-26 women, aged 17-89 years) were imaged with emergency CECT. 59 patients were injured due to traffic accidents or fall from heights. 3 patients suffered iatrogenic injuries (biopsy 2, surgery 1) and 1 patient suffered a knife stabbing. CECT detected 69 solid abdominal organ (liver, kidneys, spleen, adrenals) injuries (6 patients showed injuries in 2 organs). All patients were hospitalised and treated conservatively. Follow up was performed 3-6 days later with CEUS with the injection of SonoVue (1-2.4 ml). No new CT was performed. CEUS findings were compared to the initial CECT for assessment of improvement of solid abdominal organ injuries.

Results

CEUS showed that 52 injuries in 48 patients diminished in size. 17 injuries in 15 patients resolved completely. All patients were shortly after discharged from the Hospital with no additional imaging performed.

Conclusion

CEUS was useful for follow up of solid abdominal organ trauma in all cases with no additional CECT performed. Patients with this kind of injuries and originally scanned with CECT, following an uneventful course, can be subsequently imaged with CEUS. As a result, the number of CT scans can be diminished, thus reducing patient ionising radiation exposure, CT scanner workload, use of CT contrast agents and imaging cost.