The role of imaging in patients with ascites

Incidental findings in and around the prostate on prostate MRI: a pictorial review

Prostate MRI has seen rapid growth in use in recent years as an advanced diagnostic modality to detect focal areas of clinically significant prostate cancer, to identify an area for targeted biopsy and to guide management and surveillance. The increase in use has also led to increased diagnosis of incidental lesions arising from structures around the prostate. These incidental findings may be related to the genitourinary system or non- genitourinary system and may have a benign aetiology which needs no additional follow-up, or it may require surveillance and management. The field of view in a multiparametric prostate MRI includes other pelvic organs, neurovascular bundles, bowel, lymph nodes and bones. Being familiar with standard MRI characteristics and a sound knowledge of anatomy of the prostate and surrounding structures can help in distinguishing normal anatomy from pathology. Given that patients undertaking a prostate MRI are usually a cohort with increased anxiety from their known or suspicion of prostate cancer, it is important that radiologists are familiar with these common incidental findings to minimise anxiety to the patient, have a well-informed discussion with the referring clinician and reduce costs associated with unnecessary further testing and follow-up of benign incidental findings. Additionally, being able to diagnose more serious incidental pathologies early can be life-saving and potentially significantly alter patient management.

Management of portal hypertension and ascites in polycystic liver disease

Patients suffering from polycystic liver disease may develop Hepatic Venous Outflow Obstruction, Portal Vein Obstruction and/or Inferior Caval Vein Syndrome because of cystic mass effect. This can cause portal hypertension, leading to ascites, variceal haemorrhage or splenomegaly. For this review, we evaluate the evidence to provide clinical guidance for physicians faced with this complication. Diagnosis is made with imaging such as ultrasound, computed tomography or magnetic resonance imaging. Therapy includes conventional therapy with diuretics and paracentesis, and medical therapy using somatostatin analogues. Based on disease phenotype various (non-)surgical liver-volume reducing therapies, hepatic or portal venous stenting, transjugular intrahepatic portosystemic shunts and liver transplantation may be considered. Because of complicated anatomy, use of high-risk interventions and lack of empirical evidence, patients should be treated in expert centres.

High-Density Free Fluid on Computed Tomography: a Predictor of Surgical Intervention in Patients with Adhesive Small Bowel Obstruction

BACKGROUND

Patients with adhesive small bowel obstruction (ASBO) often develop intraabdominal free fluid (IFF). While IFF is a finding on abdominopelvic computed tomography (CT) associated with the need for surgical intervention, many patients with IFF can be still managed non-operatively. A previous study suggested that a higher red blood cell count of IFF is highly predictive of strangulated ASBO. We hypothesized that radiodensity in IFF (Hounsfield unit (HU)) on CT would predict the need for surgical intervention.

STUDY DESIGN

Patients with clinicoradiological evidence of ASBO between January 2009 and December 2013 were identified. In patients with IFF > 3 cm² identified on CT, the HU was measured in the largest pocket of IFF. A sensitivity analysis was performed to determine a high-density HU threshold. The HU of patients who underwent therapeutic laparotomy was compared with those successfully discharged with non-operative management.

RESULTS

A total of 318 patients with ASBO (median age 52 years, 56.0 % male) were identified. Of 111 patients who had IFF on CT, 55.9 % underwent therapeutic laparotomy and 15.3 % required bowel resection. Radiodensity of IFF in the operative group was significantly higher than that in the non-operative group (18.2 vs. 7.0 HU, p < 0.01). Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of high-density IFF (>10 HU) to predict the need for surgical intervention were 83.9, 65.3, 75.4, 76.2, and 75.6 %, respectively.

CONCLUSIONS

High-density IFF on CT was significantly associated with the need for surgical intervention in patients with ASBO. Prospective study to validate the predictive value of high-density IFF on CT will be warranted.

Transjugular intrahepatic portosystemic shunts (TIPS)

Transjugular intrahepatic portosystemic shunt (TIPS) is a procedure recently introduced for the management of complications of portal hypertension. TIPS can be placed in the liver with relative ease by a skilled radiologist with a low risk of mortality. The major complications following the procedure are infection, especially in patients undergoing emergency TIPS, intra-abdominal haemorrhage from capsular punctures, and long-term problems related to encephalopathy and stenosis of the shunt. Encephalopathy is more of a problem in older patients with wide diameter shunts. Stenosis of the shunt is related to pseudo-intimal hyperplasia, probably related to transection of bile ductules during placement of the shunt. In view of the high rate of encephalopathy and stenosis following the shunt, a careful follow-up of all patients, including ultrasonographic and angiographic examination of the shunt, is mandatory. TIPS is used predominantly for the control of acute variceal haemorrhage, prevention of recurrent variceal bleeding, and refractory ascites when conventional treatment has failed. However, the role of TIPS in the management of complications of portal hypertension still awaits the outcome of clinical trials.