CT in the clinical and prognostic evaluation of acute graft-vs-host disease of the gastrointestinal tract

OBJECTIVE

To determine the role of abdominal CT in assessment of severity and prognosis of patients with acute gastrointestinal (GI) graft-vs-host disease (GVHD).

METHODS

During 2000-2004, 41 patients with a clinical diagnosis of acute GI-GVHD were evaluated. CTs were examined for intestinal and extra-intestinal abnormalities, and correlated with clinical staging and outcome.

RESULTS

20 patients had GVHD clinical Stage I-II and 21 had Stage III-IV. 39 (95%) had abnormal CT appearances. The most consistent finding was bowel wall thickening: small (n=14, 34%) or large (n=5, 12%) bowel, or both (n=20, 49%). Other manifestations included bowel dilatation (n=7, 17%), mucosal enhancement (n=6, 15%) and gastric wall thickening (n=9, 38%). Extra-intestinal findings included mesenteric stranding (n=25, 61%), ascites (n=17, 41%), biliary abnormalities (n=12, 29%) and urinary excretion of orally administered gastrografin (n=12, 44%). Diffuse small-bowel thickening and any involvement of the large bowel were associated with severe clinical presentation. Diffuse small-bowel disease correlated with poor prognosis. 8 of 21 patients responded to therapy, compared with 15 of 20 patients with other patterns (p=0.02), and the cumulative incidence of GVHD-related death was 62% and 24%, respectively (p=0.01). Overall survival was not significantly different between patients with diffuse small-bowel disease and patients with other patterns (p=0.31). Colonic disease correlated with severity of GVHD (p=0.04), but not with response to therapy or prognosis (p=0.45).

CONCLUSION

GVHD often presented with abdominal CT abnormalities. Diffuse small-bowel disease was associated with poor therapeutic response. CT may play a role in supporting clinical diagnosis of GI GVHD and determining prognosis.

Differentiation between right tubo-ovarian abscess and appendicitis using CT--a diagnostic challenge

AIM

To determine CT features that can potentially differentiate right tubo-ovarian abscess (TOA) from acute appendicitis (AA; including abscess formation).

MATERIALS AND METHODS

The abdominal computed tomography (CT) images of 48 patients with right-sided TOA (average age 39.3 ± 9.8 years) and 80 patients (average age 53.5 ± 19.9 years) with AA (24 with peri-appendicular abscess) were retrospectively evaluated. Two experienced radiologists evaluated 12 CT signs (including enlarged, thickened wall ovary, appendix diameter and wall thickness, peri-appendicular fluid collection, adjacent bowel wall thickening, fat stranding, free fluid, and extraluminal gas) in consensus to categorize the studies as either TOA or AA. The diagnosis and the frequency of each of the signs were correlated with the surgical and clinical outcome.

RESULTS

Reviewers classified 92% cases correctly (TOA=85%, AA=96.3%), 3% incorrectly (TOA=6.3%, AA=1.3%); 5% were equivocal (TOA=8.3%, AA=2.5%). In the peri-appendicular abscess group reviewers were correct in 100%. Frequent findings in the TOA group were an abnormal ovary (87.5%), peri-ovarian fat stranding (58.3%), and recto-sigmoid wall thickening (37.5%). An abnormal appendix was observed in 2% of TOA patients. Frequent findings in the AA group were a thickened wall (32.5%) and distended (80%) appendix. Recto-sigmoid wall thickening was less frequent in AA (12.5%). The appendix was not identified in 45.8% of the TOA patients compared to 15% AA.

CONCLUSIONS

In the presence of a right lower quadrant inflammatory mass, peri-ovarian fat stranding, thickened recto-sigmoid wall, and a normal appearing caecum, in young patients favour the diagnosis of TOA. An unidentified appendix does not contribute to the differentiation between TOA and peri-appendicular abscess.

Mercury in traditional Tibetan medicine - panacea or problem?

Symptoms of mercury toxicity, biochemical changes, and blood/urine mercury levels were evaluated in a small group of patients. Six patients attending Delek Hospital, Dharamsala, India, taking mercury-containing traditional Tibetan medicine (TTM) (Group I), were compared with three patients taking non-mercury containing TTM (Group II) and healthy volunteers(Group II). Quantitative estimation of mercury ingestion based on chemical analysis was compared with US regulatory standards.

RESULTS

Group I were significantly older (mean 55 years+/-SE 6.4) range 26-69 years, than Group II (26.7 years+/-SE 5) range 17-34 years and Group III (32.5 years +/-SE 0.5) range 33-34 years (P =0.05). Group I took TTM on average for 51 months and had a mean of 2.5 non-specific, mercury-related symptoms. Group I had higher mean diastolic pressures (85 mmHg) than Group II (73 mmHg) (P=0.06) and more loose teeth. Mean daily mercury intake for Group I was 674 microg, estimated as 10 microg/kg per day. (Established reference dose for chronic oral exposure: 0.3 microg/kg per day.) Blood mercury levels were non-detectable, but mean urinary mercury levels for Group I were 67 microg/L (EPA levels <20 microg/L). Renal and liver function tests were not significantly different between groups and within normal clinical range.

CONCLUSIONS

Prolonged ingestion of mercury containing TTM is associated with absent blood levels, but relatively high urinary levels. Further studies are needed to evaluate toxicity and therapeutic potential.

Fat halo sign in the bowel wall of patients with Crohn's disease

AIM

To evaluate the prevalence and localization of the deposition of submucosal fat, the "fat halo sign" (FHS), using computed tomography (CT) in the bowel wall of patients with Crohn's Disease, and to assess its relation to the duration of the disease.

MATERIALS AND METHODS

The abdominal CT examinations of 100 consecutive patients were reviewed for the presence of the FHS in the bowel wall. A measurement of less than -10HU was regarded as indicative of fat. CT findings were correlated with the duration of the disease and statistically tested by simple regression analysis. The patients were divided into two groups: group A included 26 patients with a disease duration of less than 1 year and group B included 73 with a longer disease duration. In one patient disease duration was unknown. To test the relationship between disease duration and FHS the cumulative number of FHS positive and negative patients was plotted against disease duration.

RESULTS

The FHS was present in 17 of the 100 patients in 20 bowel segments, mainly in the ileum (10) and the ascending colon (8). The FHS was present in 3.8% in group A and in 21.9% in group B (p<0.0375).

CONCLUSION

The FHS was present in 17% of patients with CD. Its location was mainly in the terminal ileum and ascending colon, typical sites of the disease. Its prevalence was significantly duration dependent.

Rebound thymic enlargement on CT in adults

The objective of this study is to report the development of thymic enlargement in adults, mainly associated with chemotherapy for malignancy. The typical CT features of this phenomenon are described. The clinical data and CT studies of 13 adult patients with newly appearing thymic enlargement on CT were reviewed. These patients were followed-up mainly for malignancy. Further follow-up CTs were studied when available. Medical records were reviewed as to the primary disease, its medical treatment and the time of initial appearance of the enlarged thymus in relation to treatment. The study group included 13 adult patients, 12 with malignant disease and one with a slowly resolving pneumonia. The enlarged thymus appeared as a triangular, arrowhead-shaped structure, with a bilobed configuration and convex borders. Density measurements were consistent with homogeneous soft tissue. Location was in the anterior mediastinum, in the normal site of the thymus. In nine patients, follow-up studies were available. The observation period ranged from 5 months to 8 years from the initial appearance of the enlarged thymus. In five of the nine patients, the thymic enlargement resolved after 1-4.5 years. In four of the nine patients, the thymus remained enlarged during a follow-up ranging from 5 months to 2.5 years. Thymic enlargement, while a rare phenomenon in adults, may occur, mainly after chemotherapy. This phenomenon should be included in the differential diagnosis of a soft tissue mass appearing in the anterior mediastinum on follow-up CT in adult patients particularly following treatment for malignancy.

Importance of accurate preoperative diagnosis in the management of aggressive angiomyxoma: report of three cases and review of the literature

BACKGROUND

Aggressive angiomyxoma is a benign but locally aggressive tumor that occurs mostly in young women. Because excision is often incomplete, the risk of local recurrence is high. This report describes differences in presentation and the importance of accurate preoperative diagnosis of this rare neoplasm.

METHODS AND RESULTS

We describe three cases with different presentations. Two were initially misdiagnosed, and local recurrence necessitated reoperation. Accurate diagnosis in the third case was followed by complete excision, with no recurrence.

CONCLUSION

Aggressive angiomyxoma should be considered in the differential diagnosis of young women who present with a well-defined mass in the pelvic tissue. Accurate preoperative diagnosis should alert the surgeon to the need for wide excision, which is essential for prevention of local recurrence.

Is CT scan still necessary for staging in Hodgkin and non-Hodgkin lymphoma patients in the PET/CT era?

BACKGROUND

The clinical impact of fused PET/CT data on staging and patient management of Hodgkin disease (HD) and non-Hodgkin lymphoma (NHL) was assessed.

PATIENTS AND METHODS

A total of 103 consecutive patients with newly diagnosed NHL (n = 68) and HD (n = 35) were assessed retrospectively. Three comparisons were carried out in an attempt to assess the added value of each modality.

RESULTS

For NHL patients, there were significant differences between staging by CT versus PET/CT (P = 0.0001). Disease was upstaged by PET/CT in 31% (mostly in stages I and II) and downstaged in only 1% of patients. In 25% of the patients, the treatment approach was changed according to CT versus PET/CT findings. For HD patients, disease was upstaged by PET/CT in 32% and downstaged by PET/CT in 15% (P = NS). As for NHL, upstaging by PET/CT versus CT was evident mostly for stages I and II. The treatment strategy was altered as determined by CT versus PET/CT in 45% of the patients.

CONCLUSIONS

The addition of PET/CT to CT changed the management decisions in approximately a quarter of NHL and a third of HD patients, mostly in early disease stages. Thus, PET/CT performed as the initial staging procedure may well obviate the need for additional diagnostic CT in the majority of patients.

Early colonoscopy in patients with acute diverticulitis: results of a prospective pilot study

BACKGROUND AND STUDY AIMS

Outcomes following early colonoscopy in patients with acute diverticulitis have not previously been studied. The present study describes the effects of early colonoscopy in patients with acute diverticulitis.

PATIENTS AND METHODS

Consecutive patients hospitalized for acute diverticulitis were included in the study. In the first phase, patients with adjacent peridiverticular air or fluid on computed tomography (CT) were excluded. In the second phase of the study, only patients with free intraperitoneal air were excluded.

RESULTS

The study population consisted of 107 patients. During the first phase of the study, 49 patients were included; 10 were excluded because of peridiverticular air or fluid. The remaining 39 patients underwent uneventful colonoscopy. During the second phase of the study, 58 patients were included; four were excluded because of free air in the peritoneum. The remaining 54 patients underwent colonoscopy, and perforation of the sigmoid colon occurred in one patient with peridiverticular air. Complete colonoscopy to the cecum or to the obstructing tumor was achieved in 76 patients (81.7 %). A second colonoscopy performed 6 weeks later in 16 of the remaining 17 patients was successfully completed. Findings during the first colonoscopy were polyps in nine cases, polyp with infiltrating adenocarcinoma in one, obstructing adenocarcinoma in one, and a bone trapped in a diverticulum in another one. The latter two patients had a more protracted course and were clearly the ones who benefited most from the colonoscopy.

CONCLUSIONS

Early colonoscopy in patients with acute diverticulitis may alter the working diagnosis and be of therapeutic value. The rate of cecal intubation is lower and the perforation rate appears to be higher. A clear-cut indication therefore has to be evident clinically.

Congenital anomalies of the inferior vena cava revealed on CT in patients with deep vein thrombosis

OBJECTIVE

We describe a possible relationship between inferior vena cava anomalies and extensive thrombosis of the inferior vena cava and the iliac and femoral veins.

CONCLUSION

An anomaly of the inferior vena cava should be considered in young patients who present with deep vein thrombosis of the femoral and iliac veins. Coagulation abnormalities, frequently found in these patients, may be a contributory factor.

Pulmonary embolism—the initial manifestation of renal cell carcinoma in a young woman

We report a case of massive pulmonary embolus demonstrated on CT in a young woman presenting with dyspnea, with no known risk factors for embolism. Abdominal CT on further investigation showed a renal tumor invading the left renal vein and the inferior vena cava as the cause of the pulmonary embolus. In a patient presenting with pulmonary artery embolism without venous thrombosis, the differential diagnosis should include an occult tumor as the cause of the embolus.

Seizures as a presenting symptom of phaeochromocytoma in a young soldier

New onset of seizures in young adults is frequently related to alcohol withdrawal, toxic exposure, central nervous system trauma and neoplasm. We describe a young soldier presenting to the emergency department with seizures and transient coma. On admission, he had hypertension, marked leukocytosis, hyper-glycaemia, acidosis, elevated creatinine and elevated creatine phosphokinase of muscle origin. A thorough work-up revealed elevated urinary catecholamines, and a left adrenal mass was found on MRI and MIBG scan. The patient underwent laparoscopic adrenalectomy and completely recovered. This is the first description of seizures as a presenting symptom of phaeochromocytoma.

CT diagnosis of afferent loop syndrome

OBJECTIVE

To report the computed tomography (CT) features of afferent loop syndrome which is often clinically unsuspected.

MATERIALS AND METHODS

The CT studies of five patients with afferent loop syndrome were reviewed. These patients had undergone gastroenterostomy and other surgical procedures, for malignant neoplasms in four and for peptic ulcer in one. Patients presented between 4 months and 15 years (average 5.5 years) after surgery. Symptoms were acute in all patients, the most common symptom being abdominal pain. In addition three of the patients had chronic symptoms including recurrent episodes of abdominal pain, recurrent ascending cholangitis, jaundice and bilious vomiting.

RESULTS

The obstructed afferent loop appeared on CT as a fluid-filled tubular mass with an average diameter of 5.3cm. Valvulae conniventes were identified in all, and small intraluminal air bubbles in four. The dilated afferent loop was opacified with oral contrast material in only one patient. The loop was located in the subhepatic area in three patients and crossed the midline between the aorta and the superior mesenteric vessels in the other two. Additional findings included biliary dilatation in all five patients and signs of pancreatitis in one. Treatment was surgical in four patients (delayed for four months in one) and conservative in one.

CONCLUSION

A fluid-filled tubular structure containing small air bubbles in the right upper quadrant or crossing the midline on CT in symptomatic patients after gastroenterostomy is characteristic of a dilated, possibly obstructed, afferent loop. The diagnosis is often not suspected clinically since patients may present many years after the initial surgery. Recognition of the characteristic CT findings will avoid both inappropriate procedures such as aspiration or drainage of an obstructed afferent loop and delay in treatment.

Typhlitis as a rare cause of a psoas abscess

Typhlitis is a life-threatening necrotizing process of the cecum associated with leukemia patients who have undergone chemotherapy. We present a rare complication of typhlitis in a boy with leukemia, in whom a right psoas abscess developed secondary to the inflammatory process of the cecum, with an emphasis on the computed tomographic findings of this severe and potentially life-threatening complication. Typhlitis should be added to conditions of the gastrointestinal tract that cause a psoas abscess such as Crohn's disease, diverticulitis, appendicitis, colorectal carcinoma, and appendiceal tumor.

Perforations of the rectosigmoid colon induced by cleansing enema: CT findings in 14 patients

BACKGROUND

We report the computed tomographic (CT) features of colorectal perforations caused by cleansing enema.

METHODS

We reviewed the medical records and CT studies of all patients with colorectal perforations caused by a cleansing enema.

RESULTS

Fourteen patients (10 men, four women; average age = 80 years) were included in the study. The most common presenting symptoms were severe abdominal pain and fever. CT was performed within 48 h after the event in most patients. Extraluminal air in the perirectal fat was the most frequent finding on CT and was present in all patients. Additional findings were extraperitoneal ( n = 9), intraperitoneal ( n = 3) and /or subcutaneous ( n = 3) air, free fluid ( n = 9), extraluminal feces ( n = 8), and focal bowel wall thickening ( n = 4). No leak of contrast from the rectum was observed in any patient including the one patient in whom contrast was administered rectally. Ten patients were treated by surgery; five recovered and the other five died. The other four patients were treated conservatively and all four died.

CONCLUSION

The diagnosis of colorectal perforation can be made on CT. Because the diagnosis is not always suspected by the clinician, the radiologist may be the first to suggest it. Therefore, the radiologist should be familiar with the CT features of a potentially lethal, rectally induced perforation.

Pictorial review: adult intussusception--a CT diagnosis

Intussusception, usually thought of as a childhood condition, may be encountered in adults as well, and is then more often associated with underlying pathology. While the condition is mostly unsuspected clinically, as patients present with non-specific abdominal pain that is often of long duration, CT findings are characteristic. Examples are shown of intussusception both in the small bowel and colon. Awareness of these findings allows the radiologist to make the correct diagnosis.

Urinomas caused by ureteral injuries: CT appearance

BACKGROUND

We report the computed tomographic (CT) features of urinomas caused by ureteral injuries which are often not clinically suspected, causing delay in diagnosis.

METHODS

CT studies of 12 patients with ureteral injury were reviewed. Ureteral injuries were iatrogenic in 9 patients and traumatic in the remaining three. CT was performed between 2 and 139 days (average = 33 days) after the insult. The most common presenting symptoms were severe abdominal pain and fever. All CT studies were performed before and after intravenous contrast administration. In 11 of 12 cases, delayed scanning was added 15 min to 5 h later.

RESULTS

The sites of injury were the proximal ureter in two patients, the middle ureter in three, the distal ureter in two, and the ureteral anastomosis in five. The urinomas appeared as confined water-density fluid collections in seven patients, as free fluid (urinary ascites) in two, and as both in three. Extravasation of contrast from the ureter was observed on early scans in six patients and on delayed scanning only in the other six. The density of the opacified urinoma measured 80-200 HU. Ipsilateral hydronephrosis was observed in seven patients. Ureteral injuries were treated conservatively in eight patients and surgically in four.

CONCLUSION

Ureteral injuries after iatrogenic or penetrating trauma often are diagnosed with considerable delay. The presence of ascites or localized fluid collections in symptomatic patients after abdominal surgery or penetrating trauma should raise the possibility of a ureteral injury and prompt delayed scanning.

Is chest CT sufficient for follow-up of primary mediastinal B-cell lymphoma in remission?

OBJECTIVE

We aimed to evaluate whether chest CT alone is sufficient for follow-up assessment of patients with primary mediastinal B-cell lymphoma that is in remission.

MATERIALS AND METHODS

A retrospective review of medical records and CT examinations of patients who received a diagnosis of primary mediastinal B-cell lymphoma between January 1989 and January 2000 was performed. The first-year follow-up comprised examinations at 3-month intervals of the neck, chest, abdomen, and pelvis, with the examination modality alternating between CT and gallium scintigraphy. Patients who achieved complete remission underwent the same CT protocol twice the following year and then once a year during sequential follow-up.

RESULTS

Fifty-three patients with primary mediastinal B-cell lymphoma at presentation--31 females and 22 males, ranging in age from 17 to 61 years (average age at diagnosis, 34 years)--were studied. The follow-up time ranged from 6 to 143 months (average follow-up time, 42.4 months). Although 11 of the patients had only a partial remission, 42 patients (79%) achieved complete remission, with one patient lost to follow-up and thus excluded from study. Recurrence was diagnosed in six of these 42 patients. All six had mediastinal recurrence with additional involvement of the lungs, chest wall, pericardium, and pleura. One patient also had bone marrow involvement at recurrence.

CONCLUSION

Recurrence of primary mediastinal B-cell lymphoma in patients who achieve complete remission appears to be confined to the chest. Consequently, chest CT alone is sufficient for routine follow-up of these patients.

CT findings in congenital anomalies of the spleen

There is a wide range of congenital anomalies of the spleen. Some are common, such as splenic lobulation and accessory spleen. Other less common conditions, such as wandering spleen and polysplenia, have particular clinical significance. Radiologists need to be aware of the various congenital variants of the spleen in order to recognize clinically important anomalies and to avoid mistaking less significant ones for an abnormality. In this pictorial review, the embryology of congenital anomalies of the spleen as well as their appearance on CT are described, diagnostic pitfalls are identified and complications of the anomalies are discussed.

Widespread abdominal venous thrombosis in paroxysmal nocturnal hemoglobinuria diagnosed on CT

Paroxysmal nocturnal hemoglobinuria is a rare disorder characterized by pancytopenia. One of the main manifestations of this disease is development of widespread life-threatening venous thrombosis, which may involve multiple abdominal veins. We describe two patients with paroxysmal nocturnal hemoglobinuria with clinically unsuspected portal, splenic, and mesenteric venous thromboses that were diagnosed on computed tomography. This complication should be clinically suspected in patients suffering from paroxysmal nocturnal hemoglobinuria who present with abdominal pain, and it should be sought by the radiologist on pre- and postcontrast computed tomography.

CT findings of the chest in adults with aspirated foreign bodies

The aim of this study was to assess the imaging findings in adult patients with tracheobronchial foreign body aspiration. Nineteen patients (11 men and 8 women; age range 26-89 years) with foreign-body aspiration were retrospectively reviewed. Nine patients were outpatients with non-specific symptoms and ten were hospitalized with nonresolving pneumonia (n = 6), after detection of a dental fragment on a chest radiograph following intubation (n = 3), and there was one mentally retarded patient with empyema. An aspirated dental fragment was seen on a chest radiograph in 3 patients and an endobronchial foreign body on CT in 16, appearing as a dense structure within the bronchial lumen. The foreign body was right sided in 14 cases and left sided in 5. Three cases were missed at first interpretation. Associated findings on CT were volume loss, hyperlucency with air trapping and bronchiectasis in the affected lobe. Thirteen patients were managed with bronchoscopy, whereas 2 needed thoracotomy. In 1 patient bronchoscopy failed to detect a foreign body, indicating a false-positive CT diagnosis. One patient expelled an aspirated tablet and two refused invasive procedure. The foreign bodies found mainly were bones and dental fragments. A high clinical suspicion is necessary to diagnose a foreign body. Since CT is often used to evaluate various respiratory problems in adults, it may be the first imaging modality to discover an unsuspected aspirated foreign body in the bronchial tree.

Abdominal CT findings in nephropathic amyloidosis of familial Mediterranean fever

To evaluate the abdominal CT features of reactive amyloidosis, abdominal CT scans of 20 patients with amyloidosis of familial Mediterranean fever (FMF) were reviewed and compared with abdominal CT scans of 2 control groups: 22 patients with chronic renal failure (CRF) due to non-amyloidotic kidney diseases and 40 patients with normal kidney function. The kidney size of patients with amyloidosis of FMF were found to vary during the course of the disease from normal or slightly larger than normal at the proteinuric phase, to smaller than normal and comparable to kidney size in CRF, at the uremic stage. Compared to kidney disease of other causes, more patients with FMF-amyloidosis had dense kidneys with coarse parenchymal calcification and calcification in other abdominal organs. Patients with FMF-amyloidosis had fewer aortic calcifications than patients with non-amyloidotic kidney disease. These findings suggest that kidney disease of reactive amyloidosis may have abdominal CT findings distinguishing it from other types of kidney diseases.

Usefulness of spiral computed tomography (dual-slice mode) for the detection of coronary artery calcium in patients with chronic atypical chest pain, in typical angina pectoris, and in asymptomatic subjects with prominent atherosclerotic risk factors

The prevalence and extent of coronary calcium were retrospectively assessed by spiral computed tomography in 541 patients (mean age 62 +/- 9 years), of whom 101 had typical angina pectoris, 307 had atypical chest pain, and 133 were asymptomatic subjects with prominent atherosclerotic risk factors. The highest prevalence of coronary calcium was in men with angina pectoris (89%), whereas it was not detected in 48% of men and 56% of women with atypical chest pain.

Renal duplication with associated complications in adults: CT findings in 26 cases

AIM

To review the computed tomography (CT) findings in 26 adult patients with complicated renal duplication, and to assess whether the complications were anomaly-related or superimposed by acquired disease.

MATERIALS AND METHODS

Fifteen women and 11 men, aged 17-83 years took part in the study. All CT studies were reviewed to define the moieties affected.

RESULTS

The duplication was unilateral in 18 cases and bilateral in six, one patient had a single left kidney and the remaining one a horseshoe kidney. In 14 patients the pathology was related only to the anomaly. Upper pole abnormalities were seen in 13 patients (seven related to the anomaly) and lower pole abnormalities in five (all related to duplication). Both systems were affected in eight cases, six of them by pathological processes unrelated to duplication. Hydronephrosis of the affected collecting system was the most common imaging finding.

CONCLUSION

Computed tomography is often used to evaluate abdominal conditions in adults and may therefore be the first imaging modality to reveal a duplex kidney complicated by a pathological process. Involvement of only one moiety was frequently related to the duplication, with a predilection for the upper moiety, while involvement of both systems was used unrelated to the duplication. Zissin, R. (2001). Clinical Radiology, 56, 58-63.

CT findings in ten patients with failed renal allografts: comparison with findings in functional grafts

Our aim is to report the computed tomography (CT) features of the long-term failed renal allograft. Ten patients with failed renal transplants in whom the graft was left in situ underwent CT for various unrelated indications. The majority of the failed grafts showed marked shrinkage and coarse punctate diffuse parenchymal calcifications. Small cysts were seen in four grafts. A long-term failed renal transplant appeared on CT as a small rounded soft tissue mass. The graft was almost always heavily calcified. Lack of awareness of the nature of such a mass may mislead the radiologist in interpreting it as a space-occupying lesion.

Paraffin oil bezoar impacted in the small bowel: CT findings

A case of a paraffin oil bezoar impacted in the small bowel, resulting from the prolonged use of paraffin oil as treatment for increasing constipation in a patient with metastatic ovarian carcinoma, is described. Although pharmacobezoars are reported in the literature, we could not find a description of the CT findings of a paraffin oil bezoar.

Tracking coronary calcification by using dual-section spiral CT: a 3-year follow-up

PURPOSE

To investigate the accuracy of dual-section spiral computed tomography (CT) in tracking the progression of coronary calcification, as measured during a 3-year follow-up.

MATERIALS AND METHODS

Two hundred forty-six patients with hypertension (mean age, 66 years +/- 6 [SD]) were preselected in accordance with the International Nifedipine Study Intervention as a Goal for Hypertension Therapy protocol. Subjects had no clinical coronary arterial disease prior to the study and no cardiovascular events during follow-up. All participants underwent baseline CT (3.2-mm section thickness; reconstruction increment, 1.5 mm) and follow-up CT after 3 years. Calcification progression was defined as any increase in total calcification score (TCS) and analyzed in accordance with five baseline TCS categories: 1-9, 10-35, 36-100, 101-250, and greater than 250.

RESULTS

At baseline CT, 152 patients had a TCS greater than 0, and 106 (70%) showed progression after 3 years, while 94 had a baseline TCS of 0; of these, 26 (28%) showed progression (P: <.01 between groups). The mean TCS was significantly higher in each baseline TCS category after 3 years. The percentage increase was negatively correlated with baseline TCS (P: <.01) and ranged from 466% in the lowest category to 38% in the highest.

CONCLUSION

Dual-section spiral CT depicts significant change in TCS over time and is useful in tracking calcified coronary atherosclerosis.

CT diagnosis of malpositioned chest tubes

Insertion of a chest tube into the pleural space is standard management for various pleural disorders. Malpositioning of chest tubes in extrathoracic, intraparenchymal and mediastinal locations and in the fissures is common. Malpositioning results not only in inadequate drainage of air and fluid but may also result in increased morbidity and mortality. Diagnosis of a malpositioned tube is sometimes difficult to establish on a chest radiograph. CT, however, has proven to be extremely accurate in evaluating the position of a chest tube and has often provided additional valuable information with significant therapeutic impact.

Complications after laparoscopic gynecologic procedures: CT findings

Laparoscopic gynecologic surgery has gained worldwide popularity in the past few years, but complications of this new technique do occur. We encountered three patients who developed major complications after laparoscopic gynecologic procedures including perforation of the sigmoid colon, urinary bladder, and ureter. We report the computed tomographic findings of these cases and the diagnostic dilemmas they posed.

Postoperative pneumoperitoneum as detected by CT: prevalence, duration, and relevant factors affecting its possible significance

BACKGROUND

To determine the prevalence and duration of postoperative pneumoperitoneum as detected on computed tomography (CT) and to evaluate factors that influence postoperative pneumoperitoneum.

METHODS

One hundred three CT examinations of 89 patients performed after abdominal surgery for various indications were prospectively collected and reviewed. The presence and volume of free air were noted and correlated with patients' sex, age, and habitus, with the time interval between surgery and CT, with the type of surgery, and with the presence of drains.

RESULTS

Pneumoperitoneum was seen in 44% of examinations performed in the first 3 days after surgery and in 30% between the 4th and 18th postoperative days. The prevalence and volume of free air decreased with the time interval between surgery and CT. It was not detected in any of the 11 examinations performed beyond the 18th postoperative day. The volume of free air in the majority of examinations did not exceed 10 mL and ranged from 0.2 to 10 mL in 19 patients (66% of patients with free air). Larger volumes of free air, ranging from 10 to 20 mL and from 20 to 40 mL, were observed in 5 (17%) and 4 (14%) patients, respectively, and only one patient had more than 40 mL of free air. Free air was found significantly more often in male and in asthenic patients; age had no significant effect. Free air was more prevalent in the presence of drains. The type of surgery did not significantly influence the prevalence of postoperative pneumoperitoneum, although it was noted slightly less often after laparoscopic surgery than after open laparotomy.

CONCLUSIONS

Pneumoperitoneum is a common phenomenon after abdominal surgery, decreasing in frequency with time. The air is most often residual and not a sign of disruption of the gastrointestinal tract. Obesity, female sex, and occurrence of free air several weeks after surgery are factors suggestive of a leak, but the significance of a postoperative pneumoperitoneum on CT should be determined mainly by the clinical setting.

Hydatid cyst presenting as a soft-tissue thigh mass in a child

We report a rare case of intramuscular hydatid cyst in a boy who presented clinically as having a soft-tissue thigh mass. A high level of awareness concerning the occurrence of these cysts is important, especially in regions where Echinococcus is endemic. Surgical treatment follows the principles of malignant tumour, namely, wide surgical resection.

Imaging of mucocoele of the appendix with emphasis on the CT findings: a report of 10 cases

AIM

Mucocoele of the appendix denotes an obstructive dilatation of the appendiceal lumen due to abnormal accumulation of mucus. It is sometimes associated with pseudomyxoma peritonei, which predicts a malignant origin. We present the CT findings and additional imaging studies of 10 patients with neoplastic appendiceal mucocoele and discuss the clinical implications.

MATERIALS AND METHODS

Abdominal CT findings from 10 patients with appendiceal mucocoele were reviewed. Barium enema, US and MRI were additionally performed in three patients. There were five men and five women aged 45-80 years. Special attention was directed to the shape and nature of the mass, its relation to the caecum and the presence of ascites or peritoneal implants, as well as possible additional ovarian tumours in female patients.

RESULTS

The mucocoele was an incidental finding in five patients. They were either spherical or elongated cystic lesions, attached to the wall of the caecum, six of them with mural calcification. Ascites were present in six patients and hypodense large peritoneal implants representing pseudomyxoma peritonei in four. Pathologically the series included five cases of cystadenoma (in one, a malignant pseudomyxoma peritonei subsequently developed), four cases of cystadenocarcinoma and one villous adenoma (this patient later developed pseudomyxoma peritonei). Pseudomyxoma peritonei was found in five cases. Three women had associated ovarian cystic tumour.

CONCLUSION

The appearance of an appendiceal mucocoele is quite characteristic and can be diagnosed on CT. CT can also depict additional findings suggesting pseudomyxoma peritonei. In women with an appendiceal mucocoele the ovaries should be examined closely for cystic tumour and vice versa.

Acute diverticulitis of the small bowel: CT findings

We present the computed tomographic (CT) findings in two cases of small bowel diverticulitis, one affecting the jejunum and the other a Meckel's diverticulum. The main CT finding was that of a mass with an air-fluid collection in contiguity with small bowel loops.

Risk factors associated with postpartum ovarian vein thrombosis

Thrombosis of the ovarian vein is a remarkable process occuring within a few days of labor in 1:500-1:2000 women. Its presentation is characterized by fever, abdominal pain and occasionally by a palpable abdominal mass that in earlier years sometimes lead to explorative laparotomy. With the advent of modern imaging techniques the diagnosis can be made relatively easily. The pathogenesis has been attributed to an infectious process expanding from the uterus to the right ovarian vein and stasis. A predisposition towards thrombosis has not been so far explored. In this study we retrospectively analysed the clinical features, diagnosis and treatment of 22 patients with objective documentation of post partum ovarian vein thrombosis (POVT) and assessed potential risk factors. In 11 of the 22 patients (50%) inherited prothrombotic risk factors were detected as follows: 4 were heterozygous for factor V G1691A, 2 had protein S deficiency, one had protein S deficiency and was heterozygous for factor V G1691A, and 4 were homozygous for MTHFR C677T. Eight of the 11 patients who bore a prothrombotic predisposition underwent cesarean section. Taken together, the data suggest that POVT may result from the combined effect of an infection, cesarean section and a prothrombotic tendency.

Double-helical CT as a new tool for tracking of allograft atherosclerosis in heart transplant recipients

RATIONALE AND OBJECTIVES

Tracking the progression of allograft atherosclerosis in heart transplant recipients is currently accomplished using invasive techniques. If its monitoring feasibility is demonstrated, spiral CT could be a non-invasive alternative for this objective.

METHODS

Twenty-four consecutive heart transplant patients (21 men, 3 women, mean age 55 +/- 11 years) were scanned using double-helical CT. The first scan was performed 1.9 +/- 1.3 years after transplantation. After 2 years of follow-up, 4 patients died and the remaining 20 underwent a second scan. All scans were performed according to a previously reported double-helical CT protocol.

RESULTS

The incidence of coronary calcification at the first scan was 4.2% (1/24); it increased to 40% (8/20) at the second scan (P < 0.001). Spiral CT identified new but very mild calcific deposits in seven patients with a mean total calcium score of 6.7 +/- 4.0.

CONCLUSIONS

Double-helical CT is a viable tool to diagnose and track newly developed allograft atherosclerosis.

Positive antineutrophil cytoplasmic antibodies-associated vasculitis presenting with hemoptysis and a mediastinal mass

A patient with end-stage renal failure, due to IgA nephropathy, was found to have a mediastinal mass. Biopsy specimen of the mass showed a necrotizing vasculitis. Antineutrophil antibodies to myeloperoxidase were strongly positive. To our knowledge, no case of a mediastinal mass due vasculitis has been reported in the literature, and our observation should lead to broadening of the spectrum of clinical manifestations of vasculitis.

Bezoars in the stomach and small bowel--CT appearance

AIM

The aim of this study was to present the computed tomography (CT) appearance of trichobezoars, phytobezoars and other unusual ingested material.

MATERIALS AND METHODS

Seven patients diagnosed on CT with bezoars in the stomach or small intestine were reviewed with special attention on the characteristics of the intraluminal mass and the presence of proximal dilatation.

RESULTS

There were six women and one man aged 14-81 years. CT was performed because of abdominal pain and a palpable abdominal mass. In none of the cases was the diagnosis suspected clinically. Four patients had a trichobezoar occupying the entire lumen of the stomach. It appeared as a concentric inhomogeneous mass with entrapped air, surrounded by contrast material. In the other three patients the bezoar was confined to the small intestine and was composed respectively of vegetable fibres, ingested toilet paper and an olive stone. The first two had a mottled appearance whereas the last one was small, spherical and well defined. Variable proximal dilatation of the small bowel was present in all three.

CONCLUSION

With the increased use of CT in the evaluation of patients with non-specific abdominal pain, it is important to recognize the CT appearance of bezoars, as this diagnosis is often not suspected clinically.

Magnetic resonance imaging of hydatid cyst in skeletal muscle

The typical MRI features of hydatid cyst in soft tissue/muscle are presented and discussed.

Polysplenia syndrome detected in adulthood: report of eight cases and review of the literature

BACKGROUND

To present the computed tomographic (CT) features of the abdominal anomalies consistent with polysplenia syndrome in adults. Awareness of these abnormalities may avoid misdiagnosing characteristic findings as separate pathological processes.

METHODS

Imaging studies, mainly abdominal CT scans, of eight patients were reviewed. Attention was directed to the location of the multiple spleens, stomach, and liver and to the possible presence of a short pancreas, malrotation of the intestine, and venous anomalies. We also reviewed the CT findings of 15 adult patients described in the literature.

RESULTS

Three men and five women underwent CT for various unrelated conditions. The most common findings were multiple spleens along the greater curvature of the stomach, which were located in the right upper quadrant in six patients. The inferior vena cava was seen on the left side in seven subjects, with azygos/hemiazygos continuation in six. A preduodenal portal vein was present in seven subjects. The liver was in the midline in four patients and on the left side in two. A short pancreas was seen in four patients, intestinal nonrotation in five, and dextrocardia in two. The prevalence of these anomalies was similar to that of the reviewed cases.

CONCLUSIONS

CT proved to be an excellent imaging modality in the diagnosis of the abdominal anomalies. Some of these (a short pancreas, multiple spleens, and azygos continuation) can simulate pathological processes. Hence the importance of recognizing these CT findings as part of a syndrome.

CT angiography of superior mesenteric artery syndrome

OBJECTIVE

Our purpose was to describe the use of CT angiography and three-dimensional (3D) reconstruction in the diagnosis of superior mesenteric artery syndrome in three patients.

CONCLUSION

CT angiography combined with 3D reconstructions is a noninvasive technique that may have a complementary diagnostic role similar to that of angiography in patients with a classic clinical presentation suggestive of superior mesenteric artery syndrome. CT angiography combined with 3D reconstructions should be considered in patients who might otherwise require angiography.

Cytomegalovirus infection associated with ulcerative colitis in immunocompetent individuals

Gastrointestinal infection with cytomegalovirus (CMV) is usually found in immunocompromised patients and rarely affects immunocompetent subjects. We describe two immunocompetent patients who had primary CMV infection, and in both the disease was associated with ulcerative colitis. Both patients recovered from the CMV infection spontaneously.

Urinary excretion of orally ingested gastrografin on CT

Renal excretion of orally ingested gastrografin has rarely been reported on computed tomography (CT). We studied the unenhanced scans of 82 patients with bowel disorders or perforation to assess the prevalence of urinary contrast material (CM) in various bowel diseases. We also assessed the clinical significance of this sign. In addition, we reviewed the unenhanced CT scans of 100 randomly selected patients without bowel diseases as a control group. Twenty-nine of the 58 patients with bowel diseases, six of nine with free perforation, and one of 15 with covered perforation had CM in the urinary tract. None of the 100 without bowel disease showed urinary CM. Statistical analysis was done by using the Fisher's exact test. The prevalence of urinary CM was highest in inflammatory bowel disease, radiation enteritis, and free perforation (p < 0. 0001). This study shows that the CT finding of orally ingested gastrografin in the urinary tract differentiates patients with bowel disease from those without.

Pyelocalyceal diverticula containing milk of calcium--CT diagnosis

OBJECTIVE

To present the computed tomography (CT) findings of pyelocalyceal diverticula containing milk of calcium in seven patients.

MATERIAL AND METHODS

Three patients were examined because of flank pain, one because a malignant lesion was suspected and the three others were examined for unrelated symptoms. Three repeated scans to the kidney area were performed in every patient: an unenhanced scan, post-contrast scan and a delayed scan.

RESULTS

Unenhanced scans demonstrated an intraparenchymal round lesion with calcific material localized either at the inferior border or filling almost the entire cavity. On post-contrast scans a contrast-fluid level appeared, with some enhancement of the clear fluid in the upper part of the cyst. A further rise in the contrast-fluid level or total opacification with a density identical to that of the collecting system was obtained on delayed scans.

CONCLUSION

Pyelocalyceal diverticula containing milk of calcium present on CT as a partially calcified renal mass. Slight opacification soon after injection may be mistaken for enhancement arousing suspicion of a tumour. However, a delayed scan will demonstrate a densely opacified cyst filled with contrast from the collecting system which is virtually pathognomonic of the lesion.

Reconstruction of the sternum and chest wall with methyl methacrylate: CT and MRI appearance

The aim of our study was to define the appearance of methyl methacrylate grafts replacing resected sternum and ribs on CT and MRI and how the sternal graft may mimic an abnormally sclerotic sternum on CT images. We reviewed the CT scans of nine patients who had undergone chest wall resection (eight with malignant and one with benign disease) and reconstruction with a composite of methyl methacrylate and Marlex mesh graft. One of them had an MRI study as well. The size, shape and CT attenuation were assessed on mediastinal and bone window settings. The sternal graft was seen on mediastinal and even better on bone windows as an abnormally wide, irregularly shaped structure, somewhat denser than the normal sternum. The chest wall prosthesis replacing resected ribs was seen as a continuous dense structure and of similar attenuation as that of the sternal graft. On MRI the prosthesis appeared as a well-defined structure with no signal. Reconstruction of the chest wall with methyl methacrylate appears on CT as a diffusely dense sclerotic bone lesion not unlike a malignant lesion. The possibility of a graft has to be included in the differential diagnosis in these cases.