Unusual causes of gastrointestinal bleeding in the intensive care unit through the radiology lens.

The great majority of patients admitted to the intensive care unit (ICU) for critical gastrointestinal bleeding (GIB) will have a predictable etiology. Once the site is localized to the upper versus the lower gastrointestinal tract, the number of typically encountered etiological possibilities is quite limited. On rare occasions, the cause of GIB requiring ICU care is not one of the standard considerations, potentially leading to diagnostic and therapeutic delays. Within a short time period, three patients were admitted to our institution's medical ICU each with a different unexpected cause of GIB. All three cases generated a variety of instructive images, which are used in the present series to illustrate these conditions and the role of radiology in their evaluation and management.

Peripheral arterial occlusion due to COVID-19: CT angiography findings of nine patients.

BACKGROUND: Reports have indicated an association of large vessel peripheral arterial occlusion in the setting of Coronavirus Disease 2019 (COVID-19). While prior investigations have mostly focused on venous or cerebral arterial occlusions, we examined patients presenting exclusively with peripheral arterial extremity occlusions to investigate for any predisposing factors in this subset of COVID-19 patients. MATERIALS AND METHODS: This is a retrospective study of COVID-19 patients with peripheral arterial occlusions presenting to a multi-hospital health care system in New York City between February 1st, 2020 and April 30th, 2020. Patient data and computed tomography angiography (CTA) exams in this subset were then collected and analyzed. RESULTS: For the months of February, March, and April 2020, we identified 9 patients (ages 37-93 yrs) at our health care system who underwent extremity CTA for large vessel upper or lower extremity arterial occlusion and were diagnosed with COVID-19. Patient medical histories and clinical parameters were evaluated to identify common risk factors including obesity, hypertension, hyperlipidemia, and diabetes. Patients presented with increased inflammatory markers including ferritin, erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) as well as increased D-dimer. CONCLUSION: Our findings suggest patients with COVID-19 and comorbidities presenting with elevated inflammatory markers and D-dimer may be at increased risk of large vessel peripheral arterial occlusion.

Prostate artery embolization has long term efficacy for treatment of severe lower urinary tract symptoms from giant prostatic hyperplasia.

BACKGROUND: Patients with severe lower urinary tract symptoms (LUTS) from giant prostatic hyperplasia (GPH): prostate volume greater than 200 mL that do not respond to medical therapy may not be eligible for surgical treatments due to morbidities, technical challenges, and patient preference. This retrospective investigation examined the long-term efficacy and safety of prostatic arterial embolization (PAE) as a treatment option for severe LUTS due to GPH in a large patient cohort. METHODS: Of 529 patients who underwent PAE between January 2016 and January 2020, 72 patients had severe LUTS from GPH and were retrospectively evaluated. PAE was performed with two embolic agents in sequence: 100-250 µm particles followed by 2 mm and 3 mm coils. Clinical assessment was performed with international prostate symptoms score (IPSS), quality of life (QoL), peak flow rate (Qmax), post-void residual volume (PVR), and prostate specific antigen (PSA) measurements before and 12 months and 24 months after PAE. Prostate volume (PV) was measured by multiparametric magnetic resonance (MR) imaging before and 12 months and 24 months after PAE. RESULTS: Patients with severe LUTS from GPH experienced significant clinical improvements in IPSS, QoL, Qmax, PVR, PSA, and PV at 12 months and 24 months after PAE. Mean IPSS decreased from 26.5 to 18.0 (P < 0.01) to 10.5 (P < 0.01). Mean QoL decreased from 6.0 to 4.0 (P < 0.01) to 2.0 (P < 0.01). Mean Qmax increased from 8.0 to 14 mL/s (P < 0.01) to 18 mL/s (P < 0.01). Mean PVR decreased from 198.0 to 152.0 mL (P < 0.01) to 90 mL (P < 0.01). Mean PV decreased from 303.0 mL to 258.0 mL (P < 0.01) to 209.0 mL (P < 0.01). Mean PSA decreased from 11.2 ng/mL to 9.5 ng/mL (P < 0.05) to 7.9 ng/mL (P < 0.05). No major complications occurred. CONCLUSIONS: PAE is a safe treatment with long term efficacy for severe LUTS from GPH. PAE may be a viable therapeutic option for patients with severe LUTS from GPH whom fail medical therapy and are not candidates for surgical treatments.

Magnetic resonance enterography, colonoscopy, and fecal calprotectin correlate in colonic Crohn's disease.

BACKGROUND: Fecal calprotectin (FCP), magnetic resonance enterography (MRE), and colonoscopy are complementary biometric tests that are used to assess patients with Crohn's Disease (CD). While prior studies have evaluated the association between combinations of these tests, no study has established a correlation between all three: FCP, MRE, and colonoscopy. We prospectively investigated if there is correlation between these three tests, which may result in improved clinical outcomes that can then be used to streamline patient monitoring and treatment modification. METHODS: One hundred fifty-six patients with colonic CD were prospectively examined between March 2017 and December 2018. FCP levels, MRE, and colonoscopy were assessed in parallel on all 156 patients. Clinical CD activity was measured with the Crohn's Disease Activity Index (CDAI). CD activity with FCP was measured with a quantitative immunoassay. CD activity on MRE was measured with the Magnetic Resonance Index of Activity (MaRIA). CD activity on colonoscopy was measured with the Crohn's Disease Endoscopic Index of Severity (CDEIS). RESULTS: One hundred twelve patients (72%) had active disease (Crohn's Disease Activity Index > 150) and 44 patients (28%) were in clinical remission disease (Crohn's Disease Activity Index < 150). FCP levels, MaRIA, and CDEIS are highly correlated with positive and significant Pearson and Spearman coefficients, respectively (P < 0.0001), in univariate analyses. Regression analysis (multivariate analyses) demonstrates significant, positive correlation between FCP and MaRIA (r = 1.07, P < 0.0001) and between FCP and CDEIS (r = 0.71, P = 0.03), and between. MaRIA and CDEIS (r = 0.63, P = 0.01). CONCLUSIONS: FCP levels significantly correlate with the degree of active inflammation in patients with colonic Crohn's Disease. Improved clinical results may be achieved by using a biometric strategy that incorporates FCP, colonoscopy, and MRE together. This strategy may in-turn be used in the future to streamline monitoring disease activity and adjustment of therapy to improve long term patient outcomes.

Extrahepatic Vascular Parasitization by a Hepatocellular Carcinoma.

Hepatocellular carcinoma is the most common primary hepatic malignancy. For patients not amenable to surgical treatment, transarterial chemoembolization is a viable therapeutic alternative. Extrahepatic collateral arterial supply to the tumor may occur in a variety of scenarios and timely detection of this phenomenon is of fundamental importance to achieve optimal outcomes and response to treatment. This report presents a case of hepatocellular carcinoma that was supplied mainly by a parasitized right phrenic artery and was only successfully treated once this was identified. Further discussion of extrahepatic collateral arterial supply is also presented.

Gender Affirmation Surgery: A Primer on Imaging Correlates for the Radiologist.

OBJECTIVE. The purpose of this article is to provide an overview of common gender affirmation surgical therapies, define key anatomy, and describe select complications using multidisciplinary, multimodality approaches. CONCLUSION. Gender affirmation therapy may be tailored to the needs of each individual patient. There are three major categories of gender affirmation surgery: genital reconstruction (comprising vaginoplasty and either metoidioplasty or phalloplasty), body contouring, and maxillofacial contouring (facial feminization or masculinization). If encountered in diagnostic imaging, routine evaluation should take into consideration normal postsurgical anatomy and key associated unique complications.

Radiologist's Primer on Imaging of Common Hereditary Cancer Syndromes.

Recent advances in pathology and genetics have improved our understanding of the pathogenesis of inherited and sporadic malignancies. Detailed studies of hereditary cancer syndromes-which contribute to 5%-10% of the overall cancer burden-have shed new light on the important role of genetic abnormalities in tumor metabolism, oncologic pathways, and clinicobiologic behavior. Many inherited cancer syndromes are characterized by development of pathognomonic histotypes of neoplasms in specific target organs. Cross-sectional imaging plays an integral role in diagnosis, screening, surveillance, and treatment of patients with a wide spectrum of cancer syndromes. This article focuses on the imaging spectrum of select hereditary cancer syndromes, featuring imaging features of associated common and uncommon tumors and conditions in each syndrome, along with screening and surveillance recommendations for each condition. MRI has proved to be a useful screening modality in such patients, as these patients are often young and require prolonged screening; MRI has the added advantage of better soft-tissue contrast without ionizing radiation. The whole-body MRI protocol is also briefly discussed. The radiologist is sometimes the first physician to encounter such patients, and knowledge of these syndromes can help identify these patients earlier and impact their care by timely diagnosis and intervention. This also benefits the family members, as they can also undergo genetic testing and obtain an early diagnosis and screening. ©RSNA, 2019.

Imaging of Uncommon Causes of Large-Bowel Obstruction.

OBJECTIVE: The most common causes of large-bowel obstruction (LBO) are colon carcinoma and volvulus. Nevertheless, the increased frequency of the condition and widespread use of diagnostic imaging have revealed uncommon causes of LBO. We review the imaging features of the unusual causes of LBO on several imaging modalities, with particular emphasis on CT, along with the current literature. CONCLUSION: We propose an algorithmic approach to the radiologic evaluation of the uncommon causes of LBO.

Quantifying Language Before and After Instituting Structured CT Reports.

AIM: Our aim was to quantify the language in abdominopelvic CT reports before and after implementing structured reporting templates, specifically evaluating the terms normal and unremarkable. METHODS: We performed a search of our database for all CT abdomen and pelvis examinations before and after full template implementation. There were 1,753 studies included-878 "pretemplate" reports, 875 "posttemplate" reports. Pre- and posttemplate reports were analyzed for word count in preliminary report, word count in final report, number of changed words between preliminary and final report, and frequency of normal and unremarkable. The averages of each data point for both pre- and posttemplate reports were calculated and compared. RESULTS: Between all pre- and posttemplate reports, the total number of words and number of changes between preliminary and final reports was not significantly changed. The frequency of the word normal increased from an average of 5.29 (pretemplate) to 8.92 (posttemplate) per report (P < .0001). The frequency of the word unremarkable increased from an average of 0.11 (pretemplate) to 0.22 (posttemplate) per report (P < .0001). CONCLUSIONS: When comparing language before and after implementing structured reports, we found an increase in the frequency of normal, without any significant change in number of words per report. The increase in normal in posttemplate reports reflects a trend toward more definitive reporting, which may increase clarity and satisfaction among referring physicians. The increased use of the less definitive term unremarkable identifies an area in need of further training and improvement in our department.

MR Enterography of Inflammatory Bowel Disease with Endoscopic Correlation.

Crohn disease (CD) and ulcerative colitis (UC) are the two main forms of idiopathic inflammatory bowel disease (IBD). CD is a transmural chronic inflammatory disorder that can affect any part of the gastrointestinal tract in a discontinuous distribution. UC is a mucosal and submucosal chronic inflammatory disease that typically originates in the rectum and may extend proximally in a continuous manner. In treating patients with CD and UC, clinicians rely heavily on accurate diagnoses and disease staging. Magnetic resonance (MR) enterography used in conjunction with endoscopy and histopathologic analysis can help accurately diagnose and manage disease in the majority of patients. Endoscopy is more sensitive for detection of the early-manifesting mucosal abnormalities seen with IBD and enables histopathologic sampling. MR enterography yields more insightful information about the pathologic changes seen deep to the mucosal layer of the gastrointestinal tract wall and to those portions of the small bowel that are not accessible endoscopically. CD can be classified into active inflammatory, fistulizing and perforating, fibrostenotic, and reparative and regenerative phases of disease. Although CD has a progressive course, there is no stepwise progression between these disease phases, and various phases may exist at the same time. The endoscopic and MR enterographic features of UC can be broadly divided into two categories: acute phase and subacute-chronic phase. Understanding the endoscopic features of IBD and the pathologic processes that cause the MR enterographic findings of IBD can help improve the accuracy of disease characterization and thus optimize the medication and surgical therapies for these patients. ©RSNA, 2016.

Gastrointestinal Lymphoma: Radiologic-Pathologic Correlation.

Extranodal lymphoma is a heterogeneous group of hematologic neoplasms that can affect every abdominal organ, with distinctive pathologic, radiologic, and clinical features. The radiologic findings are closely related to the underlying pathophysiology, and an understanding of these characteristic features should facilitate recognition of extranodal lymphoma and its various subtypes. Within the abdomen, lymphoma is found most commonly in the gastrointestinal tract, especially the stomach. This article presents the findings in gastrointestinal tract lymphoma.

Prostate cancer arising in ectopic prostatic tissue within the left seminal vesicle: a rare case diagnosed with multi-parametric magnetic resonance imaging and magnetic resonance imaging-transrectal ultrasound fusion biopsy.

BACKGROUND: Benign ectopia of prostatic glandular tissue in the seminal vesicles is rare with only three prior cases reported in the literature. Prostate cancer, arising within prostatic ectopia in the seminal vesicles, has never been described and therefore presents a challenge in both diagnosis and management. CASE PRESENTATION: Herein, we report a rare case of prostatic adenocarcinoma in ectopic prostate tissue in the left seminal vesicle, without evidence of prostatic glandular involvement. This case was diagnosed on multi-parametric magnetic resonance imaging and confirmed with magnetic resonance imaging-transrectal ultrasound fusion biopsy. CONCLUSIONS: Awareness of this unusual phenomenon is significant because of the potential occurrence of malignancy to arise in unexpected, extra-glandular locations, which are not routinely sampled on routine transrectal ultrasound biopsy. However attention to lesions with characteristic multi-parametric magnetic resonance imaging features of prostate cancer, regardless of extra-glandular location, will help direct tissue sampling, facilitate a timely diagnosis and ensure appropriate management.