Objectives

To recognise the multimodality imaging features of IgG4-related disease and gain an understanding of the spectrum of presentations in the hepatobiliary and gastrointestinal systems.

Appreciate the role of imaging in the diagnosis, management and monitoring response to therapy of this condition.

Recognise common mimics and potential pitfalls for the radiologist.

Background

IgG4-related disease is a relatively recently outlined autoimmune/allergic disorder characterised by multisystem fibro-inflammatory lesions rich in IgG4-positive plasma cells, usually associated with raised serum IgG4 levels. It is a multisystem disease with a plethora of imaging findings where it may commonly mimic neoplastic and other inflammatory conditions. In particular, the abdominal manifestations can present a diagnostic conundrum with most organs potentially being involved.

Imaging findings OR Procedure findings

We will discuss the multimodality imaging features of this condition across the spectrum of findings relevant to the gastrointestinal and hepatobiliary systems. These include pancreatitis (and its varying presentations), cholangiopathy, pseudo-tumours, gastric and bowel thickening, and retroperitoneal manifestations.

Cases include the use of ultrasound, CT, MRI, nuclear medicine studies and interventional radiology in the diagnosis and management of patients.

Discussion will include practical tips for diagnosis and management as well as common pitfalls.

Conclusion

IgG4-related disease and its spectrum of clinical and imaging manifestations in the hepatobiliary and gastrointestinal systems is being increasingly recognised. Radiologists should be aware of this systemic condition as it may mimic other, potentially more serious, conditions. It has an excellent response to therapy making a prompt diagnosis important to avoid unnecessary intervention. Imaging plays a pivotal role in the management and follow up.

Objectives

Become familiar with the common anatomical appearances of pancreatic grafts and their normal post-operative appearances across a range of imaging modalities.

Recognise the spectrum of early and late post-operative complications related to pancreatic transplant; i)vascular, ii)enteric and iii)parenchymal.

'What the transplant surgeon wants to know'

Background

Whole organ pancreatic transplantation has revolutionised the management of diabetics either alone, after kidney transplant or, most commonly, as part of simultaneous pancreas-kidney transplantation.

Pancreatic grafts have enteric, vascular and parenchymal complications, with a rate of up to 55% being reported. Up to 30% have arterial or venous thrombosis, and re-laparotomy rates may be as high as one third.

The radiologist is pivotal in providing information on graft perfusion and in early diagnosis of complications; understanding the relevant surgical anatomy is paramount.

Imaging findings OR Procedure findings

-Illustrate pancreatic transplant anatomy, including common surgical variations

-Normal graft post-operative appearances across a range of imaging modalities

-Vascular complications i)venous thrombosis, ii)arterial (Y graft stenosis/occlusion), iii)pseudoaneurysm, iv)arteriovenous fistula

-Parenchymal complications i)peripancreatic collections (duct disruption, haematoma, pseudocyst, seroma and abscesses), ii)pancreatitis

-Enteric complications i)enteric leak and bleeding, ii)fistula, iii)bowel obstruction

-'What the transplant surgeon wants to know'

-Top tips for graft ultrasound

Findings are a combination of US (including contrast-enhanced), CT, MRI, and conventional angiography.

Conclusion

For timely management, it is essential that radiologists appreciate transplant arterial, venous and exocrine anatomy.

There are a huge range of potential complications; i)vascular, ii)parenchymal and iii)enteric.

Ultrasound is typically the first line imaging modality. There is an increasing role for radiological intervention to prevent further surgical intervention.

Purpose

Stable naso-ileal tube positioning has historically been challenging due to technical challenges and is accordingly rarely used in the research setting.

We describe a technique for fluoroscopic naso-ileal tube placement using a bespoke catheter developed for studies requiring sampling of ileal content. We will report the methodology and technical success of accurate, sustained tube positioning.

Material and methods

34 healthy adult volunteers were included as part of two randomised crossover studies requiring tube placement into the distal ileum for bowel content sampling, with tube position maintained over four days (institutional ethics approved).

A custom-made 400cm-long quadruple lumen catheter (Dentsleeve International Ltd. Ontario, Canada) was commissioned. This included: air channel, balloon inflation channel, radio-opaque marker, aspiration channel and tip weight. Using fluoroscopy and barium sulphate for mapping, balloon inflation facilitated spontaneous propulsion to the target site.

Technical success was defined as ileal tube placement, sustained over four days.

Results

Naso-ileal tube placement was successful in 30/34 cases (88%) and stable throughout the four-day study. Of the four failed cases, in two, the tube failed to advance satisfactorily. One was removed due to patient anxiety and one migrated proximally into the stomach.

Conclusion

We have successfully developed and trialled a novel technique for tube placement in a usually inaccessible part of the bowel using a custom catheter. The tube was placed reliably in the majority of cases. Our research required bowel content sampling during dietary manipulations, but also has potential utility for accurate regional drug delivery and in drug development.

Objectives

To recognise the multimodality imaging features of IgG4-related disease and gain an understanding of the spectrum of presentations in the hepatobiliary and gastrointestinal systems.

Appreciate the role of imaging in the diagnosis, management and monitoring response to therapy of this condition.

Recognise common mimics and potential pitfalls for the radiologist.

Background

IgG4-related disease is a relatively recently outlined autoimmune/allergic disorder characterised by multisystem fibro-inflammatory lesions rich in IgG4-positive plasma cells, usually associated with raised serum IgG4 levels. It is a multisystem disease with a plethora of imaging findings where it may commonly mimic neoplastic and other inflammatory conditions. In particular, the abdominal manifestations can present a diagnostic conundrum with most organs potentially being involved.

Imaging findings OR Procedure findings

We will discuss the multimodality imaging features of this condition across the spectrum of findings relevant to the gastrointestinal and hepatobiliary systems. These include pancreatitis (and its varying presentations), cholangiopathy, pseudo-tumours, gastric and bowel thickening, and retroperitoneal manifestations.

Cases include the use of ultrasound, CT, MRI, nuclear medicine studies and interventional radiology in the diagnosis and management of patients.

Discussion will include practical tips for diagnosis and management as well as common pitfalls.

Conclusion

IgG4-related disease and its spectrum of clinical and imaging manifestations in the hepatobiliary and gastrointestinal systems is being increasingly recognised. Radiologists should be aware of this systemic condition as it may mimic other, potentially more serious, conditions. It has an excellent response to therapy making a prompt diagnosis important to avoid unnecessary intervention. Imaging plays a pivotal role in the management and follow up.

Objectives

Become familiar with the common anatomical appearances of pancreatic grafts and their normal post-operative appearances across a range of imaging modalities.

Recognise the spectrum of early and late post-operative complications related to pancreatic transplant; i)vascular, ii)enteric and iii)parenchymal.

'What the transplant surgeon wants to know'

Background

Whole organ pancreatic transplantation has revolutionised the management of diabetics either alone, after kidney transplant or, most commonly, as part of simultaneous pancreas-kidney transplantation.

Pancreatic grafts have enteric, vascular and parenchymal complications, with a rate of up to 55% being reported. Up to 30% have arterial or venous thrombosis, and re-laparotomy rates may be as high as one third.

The radiologist is pivotal in providing information on graft perfusion and in early diagnosis of complications; understanding the relevant surgical anatomy is paramount.

Imaging findings OR Procedure findings

-Illustrate pancreatic transplant anatomy, including common surgical variations

-Normal graft post-operative appearances across a range of imaging modalities

-Vascular complications i)venous thrombosis, ii)arterial (Y graft stenosis/occlusion), iii)pseudoaneurysm, iv)arteriovenous fistula

-Parenchymal complications i)peripancreatic collections (duct disruption, haematoma, pseudocyst, seroma and abscesses), ii)pancreatitis

-Enteric complications i)enteric leak and bleeding, ii)fistula, iii)bowel obstruction

-'What the transplant surgeon wants to know'

-Top tips for graft ultrasound

Findings are a combination of US (including contrast-enhanced), CT, MRI, and conventional angiography.

Conclusion

For timely management, it is essential that radiologists appreciate transplant arterial, venous and exocrine anatomy.

There are a huge range of potential complications; i)vascular, ii)parenchymal and iii)enteric.

Ultrasound is typically the first line imaging modality. There is an increasing role for radiological intervention to prevent further surgical intervention.

Purpose

Stable naso-ileal tube positioning has historically been challenging due to technical challenges and is accordingly rarely used in the research setting.

We describe a technique for fluoroscopic naso-ileal tube placement using a bespoke catheter developed for studies requiring sampling of ileal content. We will report the methodology and technical success of accurate, sustained tube positioning.

Material and methods

34 healthy adult volunteers were included as part of two randomised crossover studies requiring tube placement into the distal ileum for bowel content sampling, with tube position maintained over four days (institutional ethics approved).

A custom-made 400cm-long quadruple lumen catheter (Dentsleeve International Ltd. Ontario, Canada) was commissioned. This included: air channel, balloon inflation channel, radio-opaque marker, aspiration channel and tip weight. Using fluoroscopy and barium sulphate for mapping, balloon inflation facilitated spontaneous propulsion to the target site.

Technical success was defined as ileal tube placement, sustained over four days.

Results

Naso-ileal tube placement was successful in 30/34 cases (88%) and stable throughout the four-day study. Of the four failed cases, in two, the tube failed to advance satisfactorily. One was removed due to patient anxiety and one migrated proximally into the stomach.

Conclusion

We have successfully developed and trialled a novel technique for tube placement in a usually inaccessible part of the bowel using a custom catheter. The tube was placed reliably in the majority of cases. Our research required bowel content sampling during dietary manipulations, but also has potential utility for accurate regional drug delivery and in drug development.