Consensus Statement of Society of Abdominal Radiology Disease-Focused Panel on Barium Esophagography in Gastroesophageal Reflux Disease.

OBJECTIVE: The Society of Abdominal Radiology established a panel to prepare a consensus statement on the role of barium esophagography in gastroesophageal reflux disease (GERD), as well as recommended techniques for performing the fluoroscopic examination and the gamut of findings associated with this condition. CONCLUSION: Because it is an inexpensive, noninvasive, and widely available study that requires no sedation, barium esophagography may be performed as the initial test for GERD or in conjunction with other tests such as endoscopy.

Dysphagia secondary to anterior cervical fusion: radiologic evaluation and findings in 74 patients.

OBJECTIVE: The objective of our study was to assess the frequency, cause, and time course of dysphagia after anterior cervical fusion (ACF). MATERIALS AND METHODS: A review of the surgical database revealed that 1789 patients underwent ACF procedures during the 8-year study period. A radiologic database review indicated that 80 of the 1789 patients underwent radiologic evaluation for the assessment of dysphagia after ACF. Three patients were excluded from the study because they had a history of dysphagia before ACF, and three additional patients were excluded because they had more recently undergone Nissen fundoplication, intubation, and radiation therapy, respectively. Modified barium swallow (MBS) studies and esophagrams of the 74 remaining patients were collected and analyzed to determine the cause of dysphagia and time course of dysphagia onset after surgery. RESULTS: Dysphagia was evaluated radiologically in 74 of the 1789 ACF patients (4.1%) using video MBS studies (n=66) and esophagography (n=26). Patients underwent radiologic evaluation from 1 to 1150 days after surgery (mean, 120 days after surgery); 76% of the patients presented more than 2 weeks after surgery. The location of the ACF in the study group was the upper, mid, and lower cervical spine in 5.4% (n=4), 55.4% (n=41), and 39.2% (n=29) of patients, respectively. Soft-tissue swelling with displacement of the pharynx or esophagus was identified in 91% of patients (n=67). More serious complications of ACF that resulted in dysphagia included surgical hardware displacement or bone graft displacement (n=18), esophageal perforation (n=3), and a retropharyngeal abscess (n=3). Pharyngeal functional abnormalities were detected in 50 patients, with penetration, aspiration, or both seen in 32. CONCLUSION: Dysphagia is an underrecognized but significant complication of ACF. After ACF, 4.1% of patients presented for radiologic evaluation of dysphagia. Although ACF procedures are most frequently performed in the lower cervical spine, dysphagia is a more common clinical problem after ACF in the mid cervical spine. Radiologic examinations should be specifically tailored to evaluate ACF patients.

Dysphagia revisited: common and unusual causes.

Dysphagia is a common clinical problem whose prevalence is increasing with the aging population in the United States. The term dysphagia is commonly used to describe subjective awareness of swallowing difficulty during the passage of a bolus from the mouth to the stomach or the perception of obstruction during swallowing. Dysphagia may be further classified as oropharyngeal or substernal, depending on the location of this sensation. It can be due to benign or malignant structural lesions, esophageal motility abnormalities, oropharyngeal dysfunction (including aspiration), neuromuscular disorders, or postsurgical changes and is also associated with gastroesophageal reflux disease. Pathologic conditions of the oral cavity, pharynx, esophagus, and proximal stomach can manifest with dysphagia. Imaging remains the preferred method for evaluating patients with dysphagia, and dysphagia is an increasingly encountered indication for radiologic evaluation. Fluoroscopic studies, including the modified barium swallow and esophagography in particular, are often used in the assessment of patients with dysphagia, and the techniques used for these studies should be tailored to the patient's needs. Fluoroscopic studies can be used to evaluate the esophagus for structural abnormalities (eg, webs, diverticula, strictures, masses) and to assess function (eg, the swallowing mechanism and esophageal motility). Knowledge of the imaging spectrum of disease entities that may cause dysphagia and thorough radiologic assessment with a tailored approach may help avoid misdiagnosis.

Imaging following bariatric procedures: Roux-en-Y gastric bypass, gastric sleeve, and biliopancreatic diversion.

Morbid obesity remains as a common and increasing health problem. Due to limited long-term success with nonsurgical weight loss measures for morbid obesity, bariatric surgery is being performed more and more often in both academic and private practice settings and has proven to be an effective treatment option with sustained weight loss, decreased morbidity, reversal of comorbidities, and prolonged life expectancies [Am J Clin Nutr 55:615S-619S, 1992; Brolin, Nutrition 12:403-404, 1996; Fisher and Schauer, Am J Surg 184:9S-16S 2002]. The Roux-en-Y gastric bypass, biliopancreatic diversion, and gastric sleeve will be discussed in terms of their expected imaging appearance and potential complications.

Internal hernia following Roux-en-Y gastric bypass surgery for morbid obesity: evaluation of radiographic findings at small-bowel examination.

PURPOSE: To characterize features of internal hernia (IH) at small-bowel follow-through (SBFT) following Roux-en-Y gastric bypass procedure (RYGBP) for morbid obesity. MATERIALS AND METHODS: The institutional review board approved this HIPAA-compliant retrospective study; informed consent was waived. Radiologic database review revealed 1655 SBFT studies over 6 years in 1282 patients after RYGBP. IH was suggested on 24 studies in 23 patients. Studies were analyzed for atypical bowel configuration, change in bowel or suture position, and obstruction. Chart review was performed to determine clinical course, treatment, and outcome. Studies from a control group of 21 RYGBP patients were similarly analyzed. Statistical comparison was performed with the Fisher exact test. RESULTS: Clinical and/or surgical evidence of IH was found following 21 SBFT studies in 20 of 1282 patients (1.6%). Atypical bowel configuration with clustered small bowel was identified on all studies. Cluster location was lateral to descending colon (n = 10), left upper quadrant (n = 6), left upper and mid abdomen (n = 3), right midabdomen (n = 2), under the gastric pouch (n = 1), and right lower quadrant (n = 1). For two studies, two locations of clustered bowel were identified. Change in jejunojejunal suture position occurred in all cases with radiopaque suture (n = 15). Other signs of IH included displaced colon (n = 19), visible entrance and exit limbs into the hernia (n = 17), stasis in clustered bowel (n = 16), densely matted bowel (n = 12), and a straight left lateral border of clustered bowel (n = 10). Partial obstruction occurred in 16 patients. Findings of atypical bowel configuration, clustered bowel, and staple line change were significant when compared with the control. CONCLUSION: IH following RYGBP is a rare but potentially fatal complication. Radiologists must be aware of this complication and its diagnostic features at SBFT.

Roux-en-Y gastric bypass surgery for morbid obesity: evaluation of leak into excluded stomach with upper gastrointestinal examination.

PURPOSE: To retrospectively evaluate the imaging features at upper gastrointestinal (GI) examination of leak into the excluded part of the stomach after the Roux-en-Y gastric bypass (RYGB) procedure and to determine the associated complications and consequences of acute versus delayed leak development. MATERIALS AND METHODS: The institutional review board approved this HIPAA-compliant study; the need for informed consent was waived. Database review revealed 1655 upper GI studies performed over 6 years in 1282 patients after an RYGB procedure. Leak into the excluded stomach was diagnosed in 48 patients (39 women, nine men; age range, 29-62 years; mean age, 46 years); these patients formed our study group. Studies were analyzed by two radiologists in consensus for extent and pattern of leak into the excluded stomach and the presence of associated complications of extraluminal leak or fistula, obstruction, and acute distention of the excluded stomach. Chart review was performed to determine clinical course, treatment, associated complications, and outcome. Patients were divided into two categories on the basis of acute versus delayed development of leak into the excluded stomach. Acute leak into the excluded stomach was diagnosed within 2 months of surgery. Delayed leak occurred more than 2 months after surgery. RESULTS: Leak into the excluded stomach occurred in the acute postoperative period (within 2 months) in 25 of the 48 patients (52%) and was associated with extraluminal leak in 22 of those 25 patients (88%). Acute leak into the excluded stomach healed in seven of the 25 patients (28%). Delayed postoperative leak into the excluded stomach occurred in 23 of the 48 patients (48%) and resulted in failed weight loss in 14 of those 23 patients (61%). Fourteen of the 48 patients (29%) underwent surgical revision for leak into the excluded stomach. CONCLUSION: Leak into the excluded stomach was identified on upper GI studies in 48 of 1282 patients (3.7%) after RYGB for morbid obesity. Acute leak into the excluded stomach may heal spontaneously; however, remote postoperative leak into the excluded stomach can result in failed weight loss and subsequent failure of the RYGB procedure.

Imaging evaluation following Roux-en-Y gastric bypass surgery for morbid obesity.

As morbid obesity continues to increase in prevalence, bariatric surgery has become a popular treatment option. Radiologists must be aware of how to perform and interpret studies in this patient population. This article discusses the Roux-en-Y gastric bypass procedure including the expected postoperative findings on upper gastrointestinal examinations and CT and the potential complications that may occur.

Adjustable laparoscopic gastric banding for morbid obesity: imaging assessment and complications.

Laparoscopic adjustable gastric banding (LAGB) is a safe and effective means of weight loss for patients who have morbid obesity. LAGB currently is the least invasive surgical treatment for morbid obesity. Radiologists must be aware of the expected postoperative imaging findings, the optimal technique for radiologic assessment, and the postoperative complications that may occur. In addition, because band-adjustment procedures often are performed fluoroscopically, the radiologist may play a direct role in the management of weight loss in patients following LAGB.

Congenital anomalies and normal variants of the pancreaticobiliary tract and the pancreas in adults: part 1, Biliary tract.

OBJECTIVE: The purpose of this article is to highlight the imaging features of congenital anomalies and normal variants of the biliary tract with contemporary imaging techniques such as MR cholangiopancreatography (MRCP), MRI, and helical CT. CONCLUSION: Recognizing findings of congenital anomalies and normal variants of the biliary tract at MRCP, MRI, and helical CT, and knowledge of the clinical significance of each entity, are important for establishing a correct diagnosis and in guiding appropriate clinical management.

Congenital anomalies and normal variants of the pancreaticobiliary tract and the pancreas in adults: part 2, Pancreatic duct and pancreas.

OBJECTIVE: The purpose of this article is to highlight the imaging features of congenital anomalies and normal variants of the pancreatic duct and the pancreas using contemporary imaging techniques such as MR cholangiopancreatography (MRCP), MRI, and helical CT. CONCLUSION: Congenital anomalies and normal variants of the pancreatic duct and the pancreas may be clinically significant and may create a diagnostic challenge. Recognition of the updated imaging features of these entities is important in clinical management and for avoiding misdiagnosis.

Radiologic evaluation following Roux-en-Y gastric bypass surgery for morbid obesity.

Morbid obesity is an increasing health problem, and bariatric surgery is becoming a popular treatment option. Radiologists must be familiar with performing and interpreting studies in this patient population. The typical postoperative findings of the Roux-en-Y gastric bypass (RYGBP) procedure for morbid obesity on upper gastrointestinal (UGI) series are presented. An overview of the potential complications that may be diagnosed with contrast studies and computed tomography (CT) is provided in addition to a description of potential pitfalls in interpreting these studies.

Pictorial review. Diagnosis of recurrent prostate cancer and its mimics at multiparametric prostate MRI.

Biochemical recurrence after treatment for prostate cancer (PCa) is a significant issue. Early diagnosis of local recurrence is important for making prompt treatment decisions and is strongly associated with patient prognosis. Without salvage therapy, the average time from development of local recurrence to distant metastasis is approximately 3 years. Biochemical recurrence does not differentiate local recurrence from systemic disease; there is no reliable way to clinically diagnose local recurrence. Recent advances in multiparametric MRI (mp-MRI) techniques have markedly improved detection of local recurrence following therapy. However, a wide variety of entities can mimic recurrent PCa at mp-MRI. Therefore, the purpose of this pictorial review is to discuss the MRI findings of locally recurrent PCa and its mimics, emphasizing the key MRI features that help to differentiate local recurrence from its mimics.

MR cholangiopancreatography.

In summary, over the past decade, MRCP has evolved not only as a feasible means of noninvasively evaluating the pancreaticobiliary tract but also as a technique with documented clinical utility. With the evolution of MRCP, there has been, by necessity, an evolution of ERCP. In fact, at some institutions MRCP has replaced diagnostic ERCP such that ERCP is reserved primarily for therapeutic interventions. When MRCP is performed in conjunction with abdominal MR and MRA, a comprehensive examination results that permits evaluation of the solid organs and vessels of the abdomen as well as the ductal systems.

Roux-en-Y gastric bypass surgery for morbid obesity: evaluation of postoperative extraluminal leaks with upper gastrointestinal series.

PURPOSE: To retrospectively evaluate the radiographic features of extraluminal leak after Roux-en-Y gastric bypass (RYGBP) surgery at upper gastrointestinal (GI) examinations in a large series of patients and to determine morbidity and mortality in those patients with leak. MATERIALS AND METHODS: The investigational review board approved this HIPAA-compliant study, and the need for patient informed consent was waived. Radiologic database review revealed 1202 upper GI studies performed over a 4-year period in 906 patients after RYGBP. Extraluminal leak was identified in 50 patients. Two patients with leaks that occurred before the study period were excluded. Of the remaining 48 patients, 12 were men and 36 were women (mean age, 45 years; range, 26-64 years). Surgery had been laparoscopic in 23 patients and open in 25. Upper GI studies were analyzed by two radiologists in consensus for the origin, extent, and severity of leaks and associated findings. Chart review was performed to determine clinical course, treatment, and outcome. RESULTS: Fifty extraluminal leaks were detected in 48 of 904 patients (5.3%) at upper GI examinations. All leaks were identified within 28 days, and, in 37 of 48 patients (77%), leakage was diagnosed within 1 week of surgery. The majority of leaks (n = 37) originated from the gastrojejunal anastomosis. Leaks also occurred at the distal portion of the esophagus (n = 5), the gastric pouch (n = 5), the oversewn jejunum (n = 2), and the distal anastomosis (n = 1). Leaks extended into the left upper quadrant in 30 patients. Obstruction or ileus was present in 35 of 48 patients (73%). Leak into the excluded stomach was observed in 15 of 48 patients. The occurrence of extraluminal leak prolonged hospital stays; organ failure occurred in 14 (29%) and death in three (6%) of the 48 patients. CONCLUSION: Extraluminal leak was identified on upper GI series in 48 of 904 patients (5.3%) after RYGBP for morbid obesity. Extraluminal leak most commonly arises from the gastrojejunal anastomosis and extends into the left upper quadrant. Extraluminal leak affects morbidity and mortality.

Abdominal imaging features of HELLP syndrome: a 10-year retrospective review.

OBJECTIVE: The purpose of this study was to describe the abdominal imaging features associated with HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome, a complication of pregnancy. CONCLUSION: The abdominal imaging features of HELLP syndrome include intraparenchymal and perihepatic hematomas and hemoperitoneum as noted on sonography, CT, and angiography.

Helical CT evaluation of acute right lower quadrant pain: part I, common mimics of appendicitis.

OBJECTIVE: The purpose of our pictorial essay is to present common mimics of appendicitis as noted on helical CT in patients with right lower quadrant pain and to highlight the features that provide clues to the diagnosis. CONCLUSION: Recognition of the findings of common diseases that simulate acute appendicitis on helical CT, along with features that help to differentiate these entities from appendicitis, is important in establishing a correct diagnosis and in guiding appropriate therapy.

Helical CT evaluation of acute right lower quadrant pain: part II, uncommon mimics of appendicitis.

OBJECTIVE: The purpose of our pictorial essay is to highlight the helical CT features of uncommon mimics of appendicitis and to provide clues to differentiate them from appendicitis. CONCLUSION: Uncommon mimics of appendicitis create a diagnostic challenge in patients with right lower quadrant pain. Recognition of the helical CT features of uncommon mimics of appendicitis is important in clinical management and avoiding unnecessary laparotomy.

Abdominal manifestations of situs anomalies in adults.

A study was made of 19 adults with situs anomalies (situs inversus [n = 10], situs ambiguous with polysplenia [n = 8], situs ambiguous with asplenia [n = 1]). No patient had congenital heart disease, bowel obstruction related to malrotation, or immune deficiency disorders. All 10 patients with situs inversus had mirror-image location of the abdominal organs relative to situs solitus; nine had dextrocardia, and one had levocardia. The eight adults with situs ambiguous with polysplenia demonstrated a spectrum of abnormalities. All had some degree of abdominal heterotaxy, including midline livers and gallbladders (n = 5), right-sided stomachs and spleens (n = 3), and rotational abnormalities of the small bowel and colon (n = 7). Other findings included multiple spleens (n = 7), interruption of the inferior vena cava (IVC) with azygous or hemiazygous continuation (n = 7), truncation of the pancreas (n = 6), and ipsilateral location of the aorta and IVC (n = 1). In the one patient with asplenia, a midline liver, right-sided stomach, bowel rotation abnormality, IVC interruption, and pancreatic truncation were noted. Recognition of the spectrum of situs anomalies is important because the altered anatomy associated with these anomalies may result in confusing imaging findings when seen in conjunction with acquired diseases.

Late biliary complications in right lobe living donor transplantation recipients: imaging findings and therapeutic interventions.

PURPOSE: The purpose of this work was to present the imaging findings of late biliary complications in right lobe living donor liver transplantation recipients and to describe radiologic techniques used to treat these complications. METHOD: A retrospective review of medical records and imaging examinations was conducted in 5 of 48 right lobe living donor recipients with known biliary obstruction treated with percutaneous biliary drainage (PBD). Two abdominal radiologists reviewed in consensus the MR cholangiopancreatography (MRCP)/MR, ultrasound (US), CT, and PBD images. RESULTS: Biliary-enteric anastomotic strictures were detected in all five recipients. In the four recipients who underwent the procedure, MRCP detected obstruction in each. CT detected obstruction in the fifth recipient. US failed to detect obstruction in one of two recipients. PBD catheters were placed without complication and relieved the obstruction in all five recipients. In addition, in three recipients, balloon dilatation of the stricture was performed and resulted in anastomotic patency. CONCLUSION: Biliary-enteric anastomotic strictures accounted for all late biliary complications and were detected correctly with MRCP and CT. The strictures were treated successfully with PBD in all instances and balloon dilatation when possible.