[Use of multidetector computed tomography for locating the site of gastrointestinal tract perforations]

Importance of high suspicion of intestinal perforation in blunt abdominal injury in patients with inflammatory bowel disease

Estimated to affect 3 million individuals in Europe alone, Crohn's disease is an inflammatory bowel disease causing transmural inflammation throughout the gastrointestinal tract. We describe the case of a patient with a known background of Crohn's disease who presented with abdominal pain following blunt abdominal trauma after a hit and run where initial diagnosis of perforation was missed on pan-computed tomography, however, diagnosis was made early due to high clinical suspicion of perforation. This suggests that current diagnostic imaging can be inaccurate, leading to delays where urgent surgery is otherwise indicated which is a cause for concern. Herein, we emphasize the importance of a high index of suspicion for perforation in patients with blunt abdominal trauma, especially where there is underlying bowel disease.

Imaging of abdominopelvic oncologic emergencies

With advancements in cancer treatment, the survival rates for many malignancies have increased. However, both the primary tumors and the treatments themselves can give rise to various complications. Acute symptoms in oncology patients require prompt attention. Abdominopelvic oncologic emergencies can be classified into four distinct categories: vascular, bowel, hepatopancreatobiliary, and bone-related complications. Radiologists need to be familiar with these complications to ensure timely diagnosis, which ultimately enhances patient outcomes.

Iatrogenic Bowel Injury Following Minimally Invasive Lateral Approach to the Lumbar Spine: A Retrospective Analysis of 3 Cases

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

Anterior approaches are often used during lumbar interbody fusion procedures. Visceral injuries (bowel injuries) are rare but represent a primary risk during anterior approaches to the lumbar spine. Left untreated, these injuries can result in significant complications. The aim of this study was to investigate the presentation and management of bowel injury cases following anterior approaches to the lumbar spine to raise the surgeon's awareness of this rare complication.

METHODS

All direct anterior, oblique anterior, and transpsoas lumbar interbody fusion surgeries performed at our institution between 2012 and 2016 were analyzed retrospectively. Charts were screened for cases requiring return to the operating room owing to a suspected bowel injury and details of the case were extracted for illustrative purposes.

RESULTS

A total of 775 anterior lumbar surgeries were conducted at a single tertiary care institution between July 2012 and June 2017. A total of 590 transpsoas lumbar interbody fusion (TPIF) surgeries were performed. Four patients, each having undergone TPIF, were suspected of bowel injury and underwent an exploratory laparotomy. At surgery, 3 patients were confirmed to have a bowel injury, giving a procedure-specific incidence of 0.51% and overall incidence of 0.39%. Among the 3 confirmed bowel injury cases, average delay between surgery and visceral injury diagnosis was 4.7 days (range 3-7 days).

CONCLUSIONS

We noted abdominal pain, distention, and fever as the most common findings in the setting of a visceral injury. A high index of suspicion and computed tomography imaging remain critical for identifying postoperative bowel injuries.

Can multidetector CT detect the site of gastrointestinal tract injury in trauma? - A retrospective study

PURPOSE

We aimed to assess the performance of computed tomography (CT) in localizing site of traumatic gastrointestinal tract (GIT) injury and determine the diagnostic value of CT signs in site localization.

METHODS

CT scans of 97 patients with surgically proven GIT or mesenteric injuries were retrospectively reviewed by radiologists blinded to surgical findings. Diagnosis of either GIT or mesenteric injuries was made. In patients with GIT injuries, site of injury and presence of CT signs such as focal bowel wall hyperenhancement, hypoenhancement, wall discontinuity, wall thickening, extramural air, intramural air, perivisceral infiltration, and active vascular contrast leak were evaluated.

RESULTS

Out of 97 patients, 90 had GIT injuries (70 single site injuries and 20 multiple site injuries) and seven had isolated mesenteric injury. The overall concordance between CT and operative findings for exact site localization was 67.8% (61/90), partial concordance rate was 11.1% (10/90), and discordance rate was 21.1% (19/90). For single site localization, concordance rate was 77.1% (54/70), discordance rate was 21.4% (15/70), and partial concordance rate was 1.4% (1/70). In multiple site injury, concordance rate for all sites of injury was 35% (7/20), partial concordance rate was 45% (9/20), and discordance rate was 20% (4/20). For upper GIT injuries, wall discontinuity was the most accurate sign for localization. For small bowel injury, intramural air and hyperenhancement were the most specific signs for site localization, while for large bowel injury, wall discontinuity and hypoenhancement were the most specific signs.

CONCLUSION

CT performs better in diagnosing small bowel injury compared with large bowel injury. CT can well predict the presence of multiple site injury but has limited performance in exact localization of all injury sites.

Multimodality approach for imaging of non-traumatic acute abdominal emergencies

"Acute abdomen" includes spectrum of medical and surgical conditions ranging from a less severe to life-threatening conditions in a patient presenting with severe abdominal pain that develops over a period of hours. Accurate and rapid diagnosis of these conditions helps in reducing related complications. Clinical assessment is often difficult due to availability of over-the-counter analgesics, leading to less specific physical findings. The key clinical decision is to determine whether surgical intervention is required. Laboratory and conventional radiographic findings are often non-specific. Thus, cross-sectional imaging plays a pivotal role for helping direct management of acute abdomen. Computed tomography is the primary imaging modality used for these cases due to fast image acquisition, although US is more specific for conditions such as acute cholecystitis. Magnetic resonance imaging or ultrasound is very helpful in patients who are particularly sensitive to radiation exposure, such as pregnant women and pediatric patients. In addition, MRI is an excellent problem-solving modality in certain conditions such as assessment for choledocholithiasis in patients with right upper quadrant pain. In this review, we discuss a multimodality approach for the usual causes of non-traumatic acute abdomen including acute appendicitis, diverticulitis, cholecystitis, and small bowel obstruction. A brief review of other relatively less frequent but important causes of acute abdomen, such as perforated viscus and bowel ischemia, is also included.

Imaging Patients With Alimentary Tract Perforation: Literature Review

Alimentary tract perforation is a frequent emergency condition. Imaging plays an important role to make an accurate diagnosis, defining the presence, the level, and the cause of the perforation, essential information to enable the most correct therapeutic choice. Plain radiography is generally performed as the first choice. In case of a clinically suspected bowel perforation, not detected on x-ray imaging, the contribution of computed tomography is essential. Magnetic resonance is not yet widely used in diagnostic workup of patients with acute abdominal pain, but it can be useful in the differential diagnosis of acute abdomen in specific patients (pregnancy and pediatric patients).

Foregut and colonic perforations: practical measures to prevent and assess them

Acute endoscopic perforations of the foregut and colon are rare but can have devastating consequences. There are several principles and practices that can lower the risk of perforation and guide the endoscopist in early assessment when they do occur. Mastery of these principles will lead to overall improved patient outcomes.

Improvement of distension and mural visualization of bowel loops using neutral oral contrasts in abdominal computed tomography

AIM: To assess and compare the image quality of 4% sorbitol and diluted iodine 2% (positive oral contrast agent) in abdomino-pelvic multi-detector computed tomography.

METHODS: Two-hundred patients, referred to the Radiology Department of a central educational hospital for multi-detector row abdominal-pelvic computed tomography, were randomly divided into two groups: the first group received 1500 mL of 4% sorbitol solution as a neutral contrast agent, while in the second group 1500 mL of meglumin solution as a positive contrast agent was administered in a one-way randomized prospective study. The results were independently reviewed by two radiologists. Luminal distension and mural thickness and mucosal enhancement were compared between the two groups. Statistical analysis of the results was performed by Statistical Package for the Social Sciences software version 16 and the Mann-Whitney test at a confidence level of 95%.

RESULTS: Use of neutral oral contrast agent significantly improved visualization of the small bowel wall thickness and mural appearance in comparison with administration of positive contrast agent (P < 0.01). In patients who received sorbitol, the small bowel showed better distention compared with those who received iodine solution as a positive contrast agent (P < 0.05).

CONCLUSION: The results of the study demonstrated that oral administration of sorbitol solution allows better luminal distention and visualization of mural features than iodine solution as a positive contrast agent.

The emergency room diagnosis of gastrointestinal tract perforation: the role of CT

Computed tomography (CT) plays an important role in the evaluation of patients presenting to the emergency department with a suspected spontaneous gastrointestinal tract (GIT) perforation. Prospective identification of the site of perforation helps the emergency department physician plan the appropriate treatment in a potentially unstable patient. The purpose of this pictorial essay is to review the CT approach a radiologist should take when evaluating the patient with suspected perforation in the emergent setting. A series of patients presenting to the emergency department with surgically proven GIT perforations were retrospectively reviewed, and key images were obtained. For the purposes of this review, the anatomy of the abdominal cavity in relation to sites of GIT perforation will be discussed. CT findings of perforation will be described, including free intraperitoneal/extraperitoneal air, bowel wall discontinuity, and localized inflammatory changes. The use of a bone window setting to increase the free air conspicuity will be emphasized. The mimics of pneumoperitoneum will be demonstrated, including pneumothorax, pneumomediastinum, and venous air. Using a systematic approach, CT can precisely determine the presence and site of a gastrointestinal perforation in a majority of patients. This greatly assists the surgeon in planning the correct surgical approach.

Free air on plain film: Do we need a computed tomography too?

Context:

Standard teaching is that patients with pneumoperitoneum on plain X-ray and clinical signs of abdominal pathology should undergo urgent surgery. It is unknown if abdominal computed tomography (CT) provides additional useful information in this scenario.

Aims:

The aim of this study is to determine whether or not CT scanning after identification of pneumoperitoneum on plain X-ray changes clinical management or outcomes.

Settings and Design:

Retrospective study carried out over 4 years at a tertiary care academic medical center. All patients in our acute care surgery database with pneumoperitoneum on plain X-ray were included. Patients who underwent subsequent CT scanning (CT group) were compared with patients who did not (non-CT group).

Statistical Analysis Used:

The Wilcoxon rank-sum test, t-test and Fisher's exact test were used as appropriate to compare the groups.

Results:

There were 25 patients in the non-CT group and 18 patients in the CT group. There were no differences between the groups at presentation. All patients in the non-CT group underwent surgery, compared with 83% (n = 15) of patients in the CT group (P = 0.066). 16 patients in the non-CT and 11 patients in the CT group presented with peritonitis and all underwent surgery regardless of group. For patients undergoing surgery, there were no differences in outcomes between the groups. After X-ray, patients undergoing CT required 328.0 min to arrive in the operating room compared with 136.0 min in the non-CT group (P = 0.007).

Conclusions:

In patients with pneumoperitoneum on X-ray and peritonitis on physical exam, CT delays surgery without providing any measurable benefit.