Nonsuppurative gas formation in the spleen after transcatheter splenic infarction

Chemoembolization for Hepatocellular Carcinoma via the Inferior Pancreaticoduodenal Artery in Patients with Celiac Artery Stenosis

Twenty-one patients with hepatocellular carcinoma (HCC) accompanied by extensive celiac artery stenosis or obstruction were treated by chemoembolization via the inferior pancreaticoduodenal artery (IPDA). The tip of the catheter was placed in the arteries in front of the confluence with the proper hepatic artery in 12 patients (group A: the proximal portion of the IPDA in 10, and common hepatic artery in 2), and in the proper hepatic artery or branches of it (group B) in 9 using a coaxial catheter system. Transient hyperamylasemia was observed in 10 of the 12 patients in group A and in 3 of the 9 patients in group B after chemoembolization. Splenic infarction developed in 8 patients in group A and in none in group B. Intrapancreatic fluid collection was present in 2 patients in group A following chemoembolization. No fatal complications were encountered. The 1-, 2-, and 3-year survival rates of the 10 patients in group A treated by only chemoembolization were 90, 57, and 23%, respectively (mean survival 780 days). The 1- and 2-year survival rates of 9 patients in group B were 85.8 and 85.8% (mean 879 days), respectively. Considering the severity of complications and the survival rates in groups A and B, chemoembolization by superselective catheterization into the hepatic artery via the IPDA is the treatment of choice. However, chemoembolization from the arteries in front of the confluence with the proper hepatic artery seems to be acceptable in cases of hypervascular HCC which fail to be superselectively catheterized.

Gas at postmortem computed tomography--an evaluation of 73 non-putrefied trauma and non-trauma cases

Postmortem computed tomography (PMCT) has become an important complement in investigating forensic cases allowing an accurate detection of gas accumulations. The present study investigated the presence and distribution of gas in a large number of non-putrefied cases of traumatic and non-traumatic deaths. Furthermore the possibility of pneumobilia secondary to blunt abdominal trauma was studied. Retrospectively, 73 cases, underwent a whole-body PMCT prior to autopsy. These were divided into four groups: penetrating trauma (20 gunshot cases, 13 stabbing cases), blunt abdominal trauma (20 cases) and a control group of 20 non-trauma cases. Exclusion criteria were visible signs of decomposition. Each group was screened for gas accumulations in the vascular system, internal organs, soft tissues and body cavities. Gas accumulations were present in 98% of the trauma cases, compared to 80% of the control group. The most affected structures and/or organs in the trauma group were soft tissues, vessels and the liver. In most cases of the trauma group gas was associated with open injuries and lacerations of vessels. Furthermore, in the gunshot group gas was frequently seen in the intracranial cavity. Pneumobilia occurred in one case of the blunt trauma group; in that control group gas was also seen, but less frequently. Gas accumulation showed a strong association with traumatic events, but even the majority of non-trauma cases showed gas accumulations. Despite the exclusion of cases with visible decomposition signs, a putrefactive origin of gas was assumed in some cases. Gas accumulations are a frequent finding in PMCT with a higher incidence in (open) trauma cases. Even though a differentiation between putrefactive and traumatic gas accumulations is still difficult, knowledge of the circumstance surrounding the case may help identify the origin of gas.

Splenic arterial interventions: anatomy, indications, technical considerations, and potential complications

Splenic arterial interventions are increasingly performed to treat various clinical conditions, including abdominal trauma, hypersplenism, splenic arterial aneurysm, portal hypertension, and splenic neoplasm. When clinically appropriate, these procedures may provide an alternative to open surgery. They may help to salvage splenic function in patients with posttraumatic injuries or hypersplenism and to improve hematologic parameters in those who otherwise would be unable to undergo high-dose chemotherapy or immunosuppressive therapy. Splenic arterial interventions also may be performed to exclude splenic artery aneurysms from the parent vessel lumen and prevent aneurysm rupture; to reduce portal pressure and prevent sequelae in patients with portal hypertension; to treat splenic artery steal syndrome and improve liver perfusion in liver transplant recipients; and to administer targeted treatment to areas of neoplastic disease in the splenic parenchyma. As the use of splenic arterial interventions increases in interventional radiology practice, clinicians must be familiar with the splenic vascular anatomy, the indications and contraindications for performing interventional procedures, the technical considerations involved, and the potential use of other interventional procedures, such as radiofrequency ablation, in combination with splenic arterial interventions. Familiarity with the complications that can result from these interventional procedures, including abscess formation and pancreatitis, also is important.

Ultrasonographic findings and differentiation of benign and malignant focal splenic lesions

The purpose of this study was to analyse the sonographic findings of focal splenic lesions with an attempt to differentiate benign lesions from malignancies. The sonographic findings of 53 cases of verified focal splenic lesions, excluding post-traumatic haematomas and phleboliths, were retrospectively analysed. Of the 53 cases, 30 cases (57%) were benign and 23 cases (43%) were malignant. The malignancies included lymphoma (n=13), metastases (n=10); while the benign lesions included cysts (n=17), infarcts (n=3), and abscesses (n=5), and one case each of haemangioma, hamartoma, spontaneous rupture, tuberculosis, and lymphangioma. Significant differences were noted between the benign and malignant groups with respect to the presence of solitary lesions (p<0.0001), anechoic mass (p<0. 0001), lesions with highly echogenic foci due to gas or calcification (p = 0.0303), hyperechoic/mixed echoic lesions (p<0. 0001), presence of extrasplenic abdominal masses (p<0.0001), and nodules with the target sign (p<0.0001). Solitary lesions, anechoic mass, and lesions with highly echogenic foci due to gas or calcification each had a positive predictive value of 85%, 100%, and 100%, respectively, for the lesions to be benign. The multifocal/diffuse lesions, presence of extrasplenic abdominal masses, hyperechoic/mixed echoic lesions, and nodules with the target sign each had a positive predictive value of 70%, 100%, 70%, and 100%, respectively, for the lesions to be malignant. In summary, focal lesions with anechoic pattern or echogenic foci due to gas or calcification are suggestive signs of benign process. The sonographic observations of multifocal or diffuse solid lesions, especially those associated with target sign or extrasplenic abdominal masses are suggestive of malignancy.

Intrahepatic gas formation without abscess after hepatic artery thrombosis in the setting of liver transplantation

We present a case in which intraparenchymal hepatic gas was observed in the absence of an abscess. This occurred following hepatic artery thrombosis in the setting of liver transplantation. An analogy is drawn to the postinfarction syndrome seen following therapeutic embolization and intrauterine fetal death. The unique features of the liver transplant and how they relate to the mechanisms of gas formation are discussed.

Splenic and portal venous thrombosis: a vascular complication of pancreatic disease demonstrated on computed tomography

Portal and splenic venous thrombosis is a rare but well recognised complication of pancreatic carcinoma and pancreatitis. We report a series of five patients with pancreatic disease in whom CT detected this complication. The appearances on CT are of an enlarged vein with a centre of lower attenuation which does not enhance following intravenous contrast injection, ring enhancement and opacification of collateral veins. Splenic vein thrombosis following pancreatitis should be considered in all patients with pancreatic disease as this complication is increasingly recognised as a cause of upper gastrointestinal haemorrhage from varices.

Partial splenic embolization for painful splenomegaly

Therapeutic splenic embolization has been commonly performed for hypersplenism, tumor palliation, and other indications, but has not been reported as a therapy specifically for pain relief. We describe 1 patient with chronic pain secondary to severe splenomegaly in whom surgery was contraindicated. Selective partial splenic embolization achieved a pain-free state for the patient without significant complications.

Sonography of the Spleen

With the advent of real-time sonography of the upper abdomen, the spleen is no longer an inaccessible organ. Real-time imaging is preferable to other conventional diagnostic methods because of its simplicity and accuracy in evaluation of the spleen and the determination of its relationship to other organs. This review of the literature details the diagnosis of splenic pathology by sonography and includes a discussion of the significance of these findings.

Computed tomography follow-up of nonsurgical treatment for hypersplenism

For the treatment of hypersplenism, transcatheter embolization of the splenic artery and collateral vessels is an alternative to splenectomy, notably in high-risk or immunosuppressed patients. After arterial occlusion and thrombosis, follow-up computed tomography scans depict progressive changes in the extent and appearance of splenic infarcts, such that these changes correlate with improved platelet counts. Computed tomography thus performs the unique role of identifying specific patterns of infarction and also differentiating internal defects, such as suppurative, gaseous, or liquefaction necrosis.

Massive splenomegaly in myeloproliferative disorders treated by splenic artery infusion of cytarabine

Ten patients with myeloproliferative disorders and massive splenomegaly were treated with splenic artery infusions of cytarabine. Nine patients demonstrated a response to treatment with reduction in spleen size. Three patients had the procedure repeated on subsequent occasions. Relief from pain was the most significant clinical benefit; lasting for up to 6 months regardless of the rate of splenic re-enlargement.

Ablation of tumor and inflammatory tissue with absolute ethanol

Absolute ethanol was used to ablate tumors, inflammatory lesions, and end-stage nephrosclerotic kidneys in 38 patients. Thirty patients had various types of renal tumors, and 3 had chronic end-stage renal failure with malignant hypertension. One patient had a fibrosarcoma of the right leg and one had a metastasis in the humerus from a renal carcinoma. A large adrenal carcinoma was treated with absolute ethanol in a patient who had liver metastases that were ablated one year after the first procedure. An additional patient had metastatic liver disease from a non-functioning adrenal carcinoma. The remaining patient had an extensive hypervascular inflammatory lesion (tuberculosis and aspergilloma) of the right upper pulmonary lobe. In addition to ethanol, coils were introduced in one patient and Gelfoam in another. The amount of ethanol used ranged from 5 to 50 ml. Twenty-two patients suffered from considerable transient pain during ethanol injection, but sedation was necessary in only 3 of them. Skin necrosis appeared in 2 patients requiring plastic reconstruction in one of them. Two patients died within 5 days of the procedure unrelated to the ablation. Two patients presented upper gastrointestinal bleeding within 2 days of the ethanol injection and one of these died in acute renal failure. One patient suffered from left colonic infarction after left renal tumor ablation, but survived for several months. Absolute ethanol was a useful and efficient sclerosing agent causing extensive tumor destruction and marked reduction of the vascularity in tumor and inflammatory lesions, but caused an 18 per cent complication rate.

Hemorrhagic pancreatitis: a complication of transcatheter embolization treated successfully by total pancreatectomy

Since pancreatitis can be produced experimentally in dogs by embolization of microspheres into the pancreatic arterial circulation, there has been speculation that intentional or inadvertent embolization of the pancreas in human subjects could also produce pancreatitis. Although such therapeutic embolization has increased, no pathologically documented case of this complication has been recorded. We have reported the first such case occurring in a patient with a large, highly vascular, nonfunctioning islet cell carcinoma of the tail of the pancreas preoperatively embolized with Gianturco coils and Gelfoam particles suspended in sodium tetradecylsulfate solution to facilitate distal pancreatectomy. The resultant hemorrhagic pancreatitis and duodenal necrosis required a total pancreatectomy. We conclude that, by itself, occlusion of the origin of the splenic and gastroduodenal arteries with coils would have been effective and without complication; however, the addition of Gelfoam particles in a sclerosing solution reduced the microscopic pancreatic circulation to a critical point and resulted in hemorrhagic pancreatitis.

Computed tomographic detection of gas within spontaneously necrotic tissue

Computed tomography (CT) is a widely accepted modality for the detection, localization, and potential therapeutic drainage of abdominal abscesses. The CT demonstration of extraluminal gas within the abdomen usually signifies the presence of an abscess. We report two cases of nonpurulent spontaneous tissue necrosis which simulated a gas containing abscess on CT. The significance of a gas-containing mass detected by CT must be interpreted cautiously since this appearance is not necessarily pathognomonic of a drainable abscess. Confirmation of purulent material within a suspected abscess collection requires documentation by percutaneous aspiration or surgery.

Splenic abscess: a review with the value of ultrasound

Five cases of splenic abscess are presented. A positive ultrasound diagnosis was made in each patient, showing a regular or ill-defined anechoic mass with large or small, high-intensity echogenic foci due to contained debris. Computed tomography performed in two cases showed intrasplenic low-density areas essentially unchanged following intravenous contrast administration. Gas was present in one of the abscesses. The clinical implications in a septicaemic patient with intrasplenic gas formation following splenic embolisation are discussed.

Gas-like radiolucencies in a popliteal cyst

A 71-year-old man with rheumatoid arthritis complained of pain and swelling in the left calf. X-ray examination of the calf disclosed radiolucencies suggestive of soft tissue gas; however, subsequent investigation revealed no evidence of infection and an arthrogram showed a dissected popliteal cyst in the area of the gas. Gas-like radiolucencies in a popliteal cyst are an unusual finding which has not been previously reported.