Intestinal interposition: the prevalence and clinical relevance of non-hepatodiaphragmatic conditions (non-Chilaiditi forms) documented by CT and review of the literature

PURPOSE

This study was done to assess the prevalence and clinical impact of non-hepatodiaphragmatic interpositions in a sample of adult patients undergoing computed tomography (CT) for a variety of medical reasons.

MATERIALS AND METHODS

From November 2008 to April 2009, two observers jointly examined the cases of intestinal interposition in 4,338 adults undergoing CT investigations. This study sought to identify not only hepatodiaphragmatic intestinal interpositions, defined as Chilaiditi, but also other forms of intestinal interposition, which we termed non-Chilaiditi. The latter were divided into five different classes on the basis of their anatomical relationships: splenorenal, retrogastric, hepatocaval, retrosplenic, and retrorenal. Moreover, a questionnaire investigating the clinical symptoms reported to be associated with Chilaiditi syndrome was given to patients exhibiting any form of intestinal interposition and to a control sample. Finally, clinical data related to the three groups were compared.

RESULTS

Of the 4,338 patients examined, 130 (3%) were found to have intestinal interposition, for a total of 143 forms: 90 Chilaiditi and 53 non-Chilaiditi. Of the latter, 30 were splenorenal, 12 retrogastric, five hepatocaval, four retrosplenic and two retrorenal. Statistical analysis showed that the Chilaiditi group suffered most symptoms (24.4%), followed by the non-Chilaiditi group (18.9%) and control cases (10.8%). Our results were validated using the χ(2) test of significance.

CONCLUSIONS

The number of non-Chilaiditi cases amounted to just over half the number of Chilaiditi cases, with the splenorenal form being by far the most frequent. Statistical analysis showed that patients with non-Chilaiditi forms of intestinal interposition had more symptoms than did controls.

Magnetic resonance imaging in the preoperative assessment of Mayer-Rokitansky-Kuster-Hauser syndrome

PURPOSE

We evaluated the accuracy of magnetic resonance imaging (MRI) in young women with primary amenorrhoea with suspected Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome (congenital absence of both vagina and uterus and presence of normal ovaries).

MATERIALS AND METHODS

Fifty-eight women (age range 14-30 years, mean 20.9) with primary amenorrhea were studied with MRI performed with a 1.0-T superconducting magnet (Philips NT Intera). All patients were examined in the supine position using a phased-array coil (four channels). Turbo spin-echo T2-weighted images were acquired in the sagittal, axial and coronal planes with the following parameters: TR 4,750-6,686, TE 100-120, FOV 350-375, 4- to 5-mm sections with a 0.4- to 0.5-mm intersection gap and NSA 6. T1-weighted images were acquired in the axial and coronal planes (TR 470, TE 15, FOV 350, 4-mm sections with a 0.6-mm intersection gap, NSA 3). Two experienced radiologists evaluated all the examinations in consensus to assess the presence, position and morphology of vagina, uterus, ovaries and kidneys and any pelvic abnormalities. MRI results were judged on the basis of laparoscopic findings in 41 patients.

RESULTS

MRKH syndrome was confirmed in 56 patients with 100% sensitivity and specificity. MRI identified bilateral Müllerian buds in 34/56 (61%) and unilateral in 10/56 (18%) patients. MRI sensitivity was 81.42%, and there was good agreement with laparoscopy (k=0.55) and full agreement in the identification of cavitation between MRI and intraoperative sonography. Both ovaries were visualised in 54 patients, with regular morphology in 46 (82.1%), polycystic in 10 (17.8%), pelvic in 47 (83.6%) and extrapelvic in eight (14.5%). We found associated abnormalities of the upper urinary tract in six patients (solitary kidney in four and ptosis in two).

CONCLUSIONS

MRI is a useful diagnostic tool in the preoperative evaluation of MRKH syndrome and is less expensive and invasive than laparoscopy. Strong cooperation between radiologists and surgeons is highly recommended.

Usefulness of chemical-shift MRI in discriminating increased liver echogenicity in glycogenosis

BACKGROUND

Glycogen storage diseases are inherited defects which cause accumulation of glycogen in the tissues. Hepatic steatosis is defined as accumulation of fat within hepatocytes. On sonography, liver shows increased echogenicity both in glycogen storage diseases and steatosis. Liver hyperechogenicity in glycogen storage diseases may depend on accumulation of glycogen and/or fat. Chemical-shift magnetic resonance imaging can discriminate tissues only containing water from those containing both fat and water.

AIM

The primary aim of the present study was to evaluate the usefulness of liver chemical-shift magnetic resonance imaging for detecting liver steatosis in patients with metabolic impairment due to glycogen storage diseases.

SUBJECTS

Twelve patients with type I (n=8) or type III (n=4) glycogen storage diseases were studied and compared to 12 obese-overweight subjects with known liver steatosis. As control group 12 lean normal voluntary subjects were recruited.

METHODS

Liver was evaluated by sonography and chemical-shift magnetic resonance imaging to calculate hepatic fat fraction.

RESULTS

A significant difference in echogenicity between patients with glycogen storage diseases and normal subjects was observed (p<0.05), while this difference was not present between overweight-obese and glycogen storage diseases patients. On the contrary, fat fraction was similar between glycogen storage diseases patients and normal subjects and different between glycogen storage diseases patients and overweight-obese (p<0.05).

CONCLUSION

The present data suggest that chemical-shift magnetic resonance imaging may exclude fat deposition as a cause of liver hyperechogenicity in subjects with glycogen storage diseases.

Potential predictive factors of osteoporosis in HIV-positive subjects

Recent reports showed a high frequency of osteopenia/osteoporosis in HIV-infected subjects. Mechanism on the basis of this alteration is still unclear, as the direct effect of virus or of antiretroviral drugs. One hundred sixty-one consecutive HIV-infected outpatients aged 30-50 years, both naive and HAART-treated for >1 year, were included. An interview questionnaire was performed to establish prior pathological, toxic, epidemiological histories, medications intake, physical activity and eating habits. Blood and urinary tests were checked to exclude concomitant diseases, as were markers of bone metabolism and vitamin D3-metabolites. Each subject underwent to a lumbar spine and left hipbone mineral density by DEXA, using WHO criteria for diagnosis of osteopenia/osteoporosis. Radiologist was unaware if the subject was receiving HAART or not. For groups' homogeneity Chi-square, Fisher's exact and Student's t tests were used. Logistic regression analysis was used to find predictors of osteopenia/osteoporosis and linear regression model to find differences in bone mass density. The demographic characteristics of the 48 naive subjects and the 113 on HAART were comparable. Eighty subjects (49.7%) showed osteopenia/osteoporosis: 22 (45.8%) naive and 58 (51.3%) on HAART (P = 0.46). Independent predictors of osteopenia/osteoporosis were female gender (OR: 3.02, 95% CI: 1.26-7.25, P = 0.01 vs. male), older age (OR: 1.10, 95% CI: 1.01-1.20, P = 0.03, for each additional year), low body mass index (OR: 0.78, 95% CI: 0.68-0.91, P = 0.001 for each additional unit) and higher HIV-RNA levels at DEXA (OR: 1.97, 95% CI: 1.16-3.34, P = 0.01 for each additional Log(10)), whereas the use of HAART (OR: 2.61, 95% CI: 0.66-10.27, P = 0.17 vs. naive) and the alterations of markers of bone metabolism were not significantly related to osteopenia/osteoporosis. Similar findings were obtained using linear regression model analysis. HIV-infected subjects have a high frequency of osteopenia/osteoporosis. Traditional risk factors are predictive of osteopenia/osteoporosis also in HIV-subjects; the association with higher HIV-RNA levels can suggest a direct role of HIV itself in the occurrence of bone disease.

Abdominal ultrasonography in inheredited diseases of carbohydrate metabolism

PURPOSE

To determine the usefulness of abdominal sonography in inherited diseases of carbohydrate metabolism.

MATERIALS AND METHODS

Thirty patients (age range, 4 months to 27 years) with glycogen storage diseases, galactosemia, disorders of fructose metabolism were studied with sonography. Echogenicity of the liver, sonographic dimensions of liver, kidneys and spleen were evaluated. Plasma blood parameters (ALT, AST, total cholesterol, triglycerides) were determined.

RESULTS

Liver was enlarged in 21/22 patients (95.4%) with glycogen storage diseases, in both subjects with disorders of fructose metabolism, and in 2/6 patients (33.3%) with galactosemia. Hepatic echogenicity was increased in 20/22 patients (90.9%) with glycogen storage diseases, and in the subject with hereditary fructose intolerance. Patients with galactosemia did not show increased liver echogenicity. Both kidneys were enlarged in 8/17 patients (47.0%) with glycogen storage disease type I. Subjects with increased hepatic echogenicity exhibited higher plasma concentrations of any blood parameter than the others with normal echogenicity (p<0.05).

CONCLUSIONS

Sonography can be useful in identification of inherited diseases of carbohydrate metabolism even if further examinations are necessary for an ultimate diagnosis.

Intra-arterial chemotherapy for unresectable pancreatic cancer

BACKGROUND

A phase II trial of a new intra-arterial chemotherapy regimen for unresectable pancreatic cancer (UPC).

PATIENTS AND METHODS

Ninety-six patients with UPC were treated with intra-arterial chemotherapy at three-weekly intervals. The schedule used was FLEC: 5-fluorouracil 1000 mg/m2, folinic acid 100 mg/m2, carboplatin 300 mg/m2; epirubicin 60 mg/m2.

RESULTS

The overall response rates by CT-scan evaluation were: 15% partial response (PR), 44% stable disease (SD), 17% progressive disease (PD). The overall median survival was 9.9 months, and 10.6 and 6.8 for UICC stage III and IV, respectively. Pain reduction occurred in 42% of patients. A weight gain > 7% from baseline occurred in 8% of patients. A total of 341 courses of FLEC were administered. Grade 3-4 hematological toxicity was seen in 25% of patients; ematemesis in 4%; grade 3 gastrointestinal toxicity in 3%; and grade 3 alopecia in 16%. One sudden death, a pre-infarction angina, and a transitory ischemic attack were observed. The only complication related to the angiographic procedure was an intimal dissection of the iliac artery.

CONCLUSIONS

The intra-arterial FLEC regimen was well tolerated and active. It requires only one day of hospitalization. Efficacy could only be assessed in a randomized study against a gemcitabine containing regimen.

[AIDS-related pulmonary Kaposi's sarcoma: role of high-resolution computerized tomography]

INTRODUCTION

HIV-related Kaposi sarcoma (KS) is characterized by lesion multifocality, stronger progression and recurrent involvement of some internal organs. Pulmonary lesions are found in 18-47% of cases and not necessarily associated with skin involvement. Lung infections are potentially life-threatening and their early and prompt demonstration is a crucial step for both treatment planning and the prognosis of this severe disease. As a rapid recognition of a pulmonary condition leads to a complete or partial regression in at least 50% of cases, we investigated the role and the diagnostic yield of HRCT in depicting HIV-related KS.

MATERIAL AND METHODS

The findings of thirty-nine patients with HIV-related pulmonary KS were retrospectively reviewed. We excluded the patients with associated diseases and incomplete radiologic findings and included 12 patients who had a chest radiograph and a HRCT scanning at least. HRCT showed parenchymal and subpleural micronodules (< 10 mm) and macronodules (> 10 mm), with the halo sign in some cases; perivascular and peribronchial infiltrates, linear or irregular opacities, pleural effusions and enlarged lymph nodes were also seen. Chemotherapy response was also evaluated.

RESULTS

All 12 patients had advanced AIDS. The chest films showed abnormal patterns, such as peribronchial and perivascular infiltrates which were most often in midlower pulmonary lobes (88.9%) and often symmetric. Nodules were depicted in 50% of cases and were often associated with peribronchial and perivascular infiltrates; they were always bilateral and characterized by the presence of macronodules in most cases. Eleven of 12 HRCT examinations were considered sufficiently accurate for evaluation, while a pleural effusion prevented lung assessment in one case. Peribronchial and perivascular infiltrates were the most frequent abnormal findings (83.3%), with bilateral involvement in 80% and mostly in the midlower lobes (90%). Parenchymal and subpleural nodules were depicted in 58.3% of cases and always had irregular borders; the halo sign was seen around the nodules in 2 cases and macronodules were found in 2 cases. Pleural effusions were seen in 3 cases and enlarged lymph nodes in 4. Lung KS diagnosis was always confirmed at pathology. The response to chemotherapy (ABV protocol) was evaluated in 5 patients: transient and definitive regressions were observed in 1 and 2 cases, respectively, and disease progression was seen in 2 cases.

CONCLUSIONS

HRCT allows the accurate assessment of pulmonary KS in its different stages detailing the disease and its spread, which makes biopsy easier. It also permits to avoid more invasive diagnostic procedures and it is useful in the follow-up after chemotherapy.

[Invasive aspergillosis in AIDS: findings with high-resolution computerized tomography]

PURPOSE

To review the early CT findings of invasive aspergillosis in AIDS patients who are at high risk for developing this infection. Early recognition of invasive fungal disease is imperative in these patients, and longer survival can be achieved with early CT detection and prompt institution of high-dose antifungal therapy.

MATERIAL AND METHODS

February, 1992 to December, 1994, sixteen cases of invasive pulmonary aspergillosis in AIDS patients were retrospectively reviewed. All patients underwent a chest radiograph and high-resolution Computed Tomography (HRCT) and the results were confirmed by pathology.

RESULTS

11/16 cases (68.8%) showed angioinvasive aspergillosis, characterized by nodules surrounded by the halo sign and cavitations; the remaining 5 patients (31.2%) showed invasive aspergillosis of the airways with centrilobular nodules and/or peribronchial consolidations. Five cases of extrapulmonary fungal dissemination were also observed.

CONCLUSIONS

HRCT is a sensitive noninvasive method for evaluating early angioinvasive aspergillosis because the halo sign is characteristic enough to allow an early presumptive diagnosis. Invasive aspergillosis of the airways presents no characteristic radiologic pattern. However, the association of the clinical and radiologic pattern allows prompt institution of high-dose antifungal therapy.

[Survival of 184 patients with hepatocellular carcinoma in cirrhotic liver treated with chemoembolization. A multicenter study]

INTRODUCTION

We report the results of a multicenter study of 184 cirrhotic patients with hepatocellular carcinoma (HCC) treated with transcatheter arterial chemoembolization (TACE) and compare our results with those reported in the literature.

MATERIAL AND METHODS

We treated 184 cirrhotic FNB-proved HCC patients with TACE in a 2 years' period; 159 were men and 25 women and their mean age was 59 years (range: 46-75 years). TACE was performed with selective or superselective injection of Doxorubicin chlorhydrate (20-50 mg) mixed with Lipiodol Ultrafluid before embolization with Spongostan. This procedure was repeated after 4-6 weeks for at least 3 cycles. Follow-up was performed by means of periodic US, CT and MR scans and by assessment of the clinical status and serum biochemical tests--alpha-fetoprotein, platelet and blood cell counts, protein electrophoresis, bilirubin and other standard liver and renal function tests. TACE results were assessed comparing site, size and local spread of tumor and TACE technique (lobar or segmental, number of performed procedures) with survival in each patient. The lesion was single in 85 (46.2%) and multiple in 99 (53.8%) patients. It exceeded 5 cm in 128 patients (69.5%) and was < 5 cm in 57 (30.5%).

RESULTS

Angiography, CT and MRI showed complete necrosis in 148 patients (80.4%) and an unchanged pattern in 36 (19.6%). Overall survival rates were 95.7% at 6 months, 78.3% at 1 year, 46.0% at 2 years, 40.0% at 3 years. The best responses were obtained with lesions < 5 cm--with 100% survival at 6 months, 94.8% at 12 months, 71.4% at 18 months, 54.7% at 24 months and 50.0% at 36 months. Other factors affecting treatment response were singleness of lesion (96.4% at 6 months, 93.9% at 12 months, 71.4% at 18 months, 58.9% at 24 months, and 50.0% at 36 months) and at least 3 cycles of TACE (100% at 6 months, 87.8% at 12 months, 70.1% at 18 months, 48.7% at 24 months and 37.5% at 36 months). Abdominal pain and fever were the most frequent complications, particularly in the first TACE procedure, but both were mild and transient. Lipiodol cholecystitis was found in 3 patients but they were asymptomatic. No patients had evidence of cardiac toxicity or experienced significant leukopenia or thrombocytopenia as a result of systemic toxicity from Doxorubicin.

CONCLUSIONS

We can conclude that TACE proves to be an efficacious treatment in the HCC patients who cannot undergo surgery.

[High-resolution computed tomography (HRCT) versus bronchoscopy in predicting the need for bronchial embolization in hemoptysis]

September, 1992, through May, 1994, thirty patients with hemoptysis were examined with CT, HRCT and bronchoscopy. Our study was aimed at comparing CT and HRCT with fiberoptic bronchoscopy in the identification and assessment of hemoptysis causes and of lesion shape and extent. These data are of basic importance for the interventional radiologist when an intravascular treatment is scheduled. The causes of hemoptysis included cystic fibrosis in 14 patients, bronchiectasis and bronchiolectasis in 11, tuberculosis in 3 and aspergillosis in one. In only one patient the etiology of hemoptysis remained undetected. Among the most common patterns, the "ground-glass" one was the main finding (50%), while bronchiectasis and bronchiolectasis were demonstrated in 40% of the patients. In the extent 10% of cases the cause of hemoptysis was identified with small lesions as a result of previous tubercular infections. Among the causes of hemoptysis, our study included only inflammatory, and not neoplastic, diseases. In 97% of patients, CT and HRCT allowed the diagnosis of lesion type, extent and site, while bronchoscopy did the same in only 35% of patients, because of its lack of accuracy in identifying and characterizing peripheral lesions. Our results suggest that CT and HRCT should be performed after bronchoscopy and before bronchial embolization. Confirming literature data, our study proves CT and HRCT to play a basic role in the diagnosis of the inflammatory conditions causing hemoptysis.

[Computerized tomography in the diagnosis of Crohn disease]

Fifty patients affected with Crohn's disease were examined with CT in a 12-month period; 39 of them underwent an intestinal enema and 24 a colon enema. Our goal was to assess the comparative contribution of CT and conventional radiology to the diagnosis of this disease. CT proved to be the method of choice to diagnose wall diseases with colon or small bowel wall thickening, which is usually homogeneous as demonstrated in 94% of the patients, intraabdominal abscesses in 3 patients (6%), perianal (4%), enterocutaneous (2%) and enteromuscle (2%) fistulas. CT was comparable to barium studies for rectovaginal (2%) and enterocolic (4%) fistulas. Conventional radiology was better than CT to assess mucosal diseases and ileum-ileal fistulas which were demonstrated with small bowel enema in 4 patients and in one patient only with CT. Therefore, we believe CT to be a complementary method to barium studies and a necessary tool for the correct staging of this disease, especially relative to the diagnosis of extramural lesions.

[The radiological pictures of pulmonary tuberculosis in HIV+ patients]

Mycobacterial infections can be found in 10% of AIDS patients. Seventy cases with HIV+ infection were examined: they exhibited clear alterations of the chest and contemporaneous isolation and identification of mycobacteria. Primary tuberculosis is the most frequent manifestation in these patients. Alveolar parenchymal mono/bilateral infiltrates are the radiographic patterns of this pulmonary condition; they usually present without excavation (45.7%). Hilar and/or mediastinal lymph nodes are usually associated, and no pleural effusions. The main problem is the differential diagnosis with pneumocystis carinii pneumonia, especially the form involving lung apices. A correlation has been observed between the blood level of T-lymphocytes and their subsets (CD4 level) and the radiographic patterns of tuberculosis in AIDS patients. In fact, pleural effusion is frequent in patients with CD4 less than 200, while miliary nodules and cavitations are more frequent in the cases with CD4 greater than 200.

Unusual CT features in ruptures of abdominal aortic aneurysms

The authors present two cases of impending rupture of abdominal aortic aneurysms correctly diagnosed by means of some unusual CT findings. The clinical signs were not clear. On CT examination, despite the absence of haematomas, minor, but precise, changes allowed the correct diagnosis: loss of definite contours of the aneurysm, non-homogeneous peri-aortic and peri- and para-renal adipose tissue, thickening of the renal fascia and a thin fluid collection over the psoas muscles.

[Bronchial embolization in the prevention of hemoptysis caused by cystic fibrosis]

Bronchial arteries embolization is a routine treatment of hemophtysis. In patients affected by cystic fibrosis hemophtysis is often very serious, dangerous for their life. The extent of pulmonary lesions, the frequent bilaterality and respiratory dysfunction are contraindications to operation. The authors report their experience on three patients affected by cystic fibrosis with hemophtysis, in which bronchial embolization has been the only therapeutic choice. It performed a good result with immediate stopping of hemophtysis. In all three cases results were not serious relapses, but only rare slight hemophtysis.

[Intravenous digital angiography in the control of the patency of extra-anatomical bypasses of the legs]

The authors report their experience over 58 cases of extra-anatomical by-pass for revascularity of lower limbs (31 axillo-femoral, 21 femoro-femoral, 2 femoro-popliteal, 4 axillo-femoral) checked using intravenous digital angiography (IDA). This method is useful for its poor invasivity. As a matter of fact intravenous peripheral injection of contrast medium is proved to be sufficient. Moreover it allows clear evidence of anastomosis morphology and functionality both peripherally and proximally. Peripheral flow is also well seen when by-pass works. IDA fills now an area where traditional angiography was not employed for the difficulties in using arterial way. Selective catheterization was also necessary for the evidence of the two far-away districts (axillo-femoral).

[Value of computerized tomography in the diagnosis of lumbar disk hernia]

Two hundred-twelve patients with clinical suspect of herniated disk in the lumbar spine were examined by computed tomography (CT). Eighty-one patients underwent a surgical operation. The CT findings were correlated with myelographic and surgical findings. The CT diagnosis of herniated disk were intraoperatively confirmed in seventy-three patients (90,1%). The authors expose constant and accurate CT findings of herniated disk. CT should be considered as an excellent screening procedure for the diagnosis of herniated disk.

[Splenic artery aneurysms in patients with portal hypertension (author's transl)]

The authors report on their experience of two cases of splenic artery aneurysm in patients with cirrhosis and portal hypertension. It is underlined the determinant, causal role of the hemodynamic changes occurring in the circulation of the liver, spleen and portal vein in patients with or without portal hypertension. Above changes are thought to be responsible of the formation of splenic artery aneurysm in line with the current literature.

The human urinary gastric inhibitor displays blood-group activity

The human urinary glycoprotein with gastric antisecretory activity displays a marked blood-group activity corresponding to the blood-group of the subject examined. Several studies exclude the possibility that the activity is due to contaminants.

[Polyarteritis nodosa: evolution of the angiographic findings and uncommon localizations (author's transl)]

A series of 10 patients with polyarteritis nodosa have been studied by means of angiographic investigations with selective arteriography of the different visceral districts. The attention is focused on some unusual localizations of the typical lesions such as aneurysms of the supra-renal artery of the coronary artery and of the femoral artery. Up to now these localizations have been described only in post mortem examinations. Such localizations should be considered as a demonstration of the multicentric spread of the disease, independently from its degree of development. On the other hand a correlation seems to exist between the evolution of the disease in the increase in size of the aneurysmatic lesions as well as with the simultaneous presence of all the angiographic signs.

Immunogenicity and immunosensitivity of urethane-induced murine lung adenomata, in relation to the immunological impairment of the primary tumour host

The depression of the immunological status of BALB/c mice treated during infancy with two different doses of urethane, alone or combined with cortisone, was evaluated by counting the number of plaque forming cells at 30 or 50 days of age. The incidence of lung adenomatous nodules was directly related to the degree of immunological impairment at 50 days of age. Twenty-seven lung adenomata were tested in an in vitro system involving spleen cells immune against the same single tumour used as target cell. Eighty-six per cent of tumours in the most immunodepressed group of mice were positive compared with 20-40% in the less immunodepressed groups. Syngeneic cross-reaction tests showed that non-immunogenic tumours were immunosensitive since 66% positive tests were obtained when target cells belonging to the less immunodepressed groups were tested with spleen cells of mice immunized with immunogenic adenomata.