Distribution of abdominal adipose tissue as a predictor of hepatic steatosis assessed by MRI.

AIM: To evaluate the relationship between the distribution of visceral and subcutaneous adipose tissue and hepatic steatosis assessed using magnetic resonance imaging (MRI). MATERIALS AND METHODS: One T1-weighted, in-/out-of-phase, single-section sequence at the L3/L4 level and one multi-echo gradient MRI (MGRE) sequence were performed on 65 patients [19 females and 46 males; age 57+/-9.5 years; body mass index (BMI) 31+/-5.1kg/m(2)]. Visceral adipose tissue (VAT), subcutaneous adipose tissue (SAT) surfaces, and hepatic steatosis were automatically calculated using in-house software. Weight, height, BMI, waist circumference, hip circumference, and waist:hip ratio were recorded. The probability of having a steatosis greater than 10% on MRI was evaluated by receiver operating characteristic (ROC) curves. RESULTS: The anthropometric parameter best correlated to hepatic steatosis was the waist-to-hip ratio (r=0.301). VAT and proportion of VAT were correlated to liver fat content (r=0.307 and r=0.249, respectively). No significant correlations were found for BMI, hip circumference, and SAT. The area under the receiver operating characteristics (AUROCs) for the relationship between liver steatosis and BMI, waist circumference, waist:hip ratio, VAT surface, and proportion of VAT, were respectively 0.52, 0.63, 0.71, 0.73 and 0.75. CONCLUSION: Adipose tissue distribution is more relevant than total fat mass when assessing the possibility of liver steatosis in overweight patients.

Liver fibrosis staging with contrast-enhanced ultrasonography: prospective multicenter study compared with METAVIR scoring.

We prospectively assessed contrast-enhanced sonography for evaluating the degree of liver fibrosis as diagnosed via biopsy in 99 patients. The transit time of microbubbles between the portal and hepatic veins was calculated from the difference between the arrival time of the microbubbles in each vein. Liver biopsy was obtained for each patient within 6 months of the contrast-enhanced sonography. Histological fibrosis was categorized into two classes: (1) no or moderate fibrosis (F0, F1, and F2 according to the METAVIR staging) or (2) severe fibrosis (F3 and F4). At a cutoff of 13 s for the transit time, the diagnosis of severe fibrosis was made with a specificity of 78.57%, a sensitivity of 78.95%, a positive predictive value of 78.33%, a negative predictive value of 83.33%, and a performance accuracy of 78.79%. Therefore, contrast-enhanced ultrasound can help with differentiation between moderate and severe fibrosis.

[Postoperative imaging of the cardia and stomach]. / Imagerie post-opératoire du cardia et de l'estomac.

In addition to treatment of complications from peptic ulcer disease, gastroesophageal reflux and gastric cancer, bariatric surgical procedures have increased over the recent years. Complications after gastric surgery are imaged with upper gastrointestinal contrast studies and CT. This imaging is not always easy and it is important for radiologists to know the different types of surgical techniques and to be familiar with normal postoperative anatomical and pathological findings.

[Abdominal trauma: spectrum of lesions]. / Traumatismes abdominaux: les lésions élémentaires.

Abdominal injuries are more often observed in the setting of polytrauma. Detection and accurate description of hemoperitoneum, solid organ injuries (contusion, hematoma, laceration, fracture), bowel perforation and arterial bleeding allow optimal multidisciplinary management. Mesenteric and bowel injuries are often difficult to diagnose and may be masked by the presence of more frequent injuries (spleen, liver). MDCT is the gold standard imaging modality for severe blunt abdominal trauma.

[Image-guided percutaneous gastrostomy]. / Gastrostomie Percutanée Radiologique.

Gastrostomy is mainly used to provide longterm enteral nutrition. Percutaneous techniques are generally preferred to surgery except for specific cases. Image-guided percutaneous gastrostomy, currently used less than the gastroscopy-guided technique, is a simple, reliable and advantageous technique in managing these frequently debilitated patients. The different aspects of the procedure will be described: indications, contraindications, technique, follow-up, main complications and technical variations.

Liver fibrosis, cirrhosis, and cirrhosis-related nodules: Imaging diagnosis and surveillance.

Although biological scores and elastography continue to yield the best results, imaging retains a crucial role in the diagnosis of liver fibrosis and cirrhosis. First, digestive symptoms or biological liver test abnormalities often lead the referring physician to request an abdominal ultrasound, and with an experienced operator, accuracy of ultrasound can reach 85% for the diagnosis of severe fibrosis or cirrhosis. Second, imaging could lead to discovery of nonsymptomatic fibrosis or cirrhosis, with an estimated prevalence of 0.5-2.8% in the population. After diagnosis, imaging is central in the follow-up of cirrhosis. It is used to detect worsening of portal hypertension and hepatocellular carcinoma (HCC). Because many nodules are present in a cirrhotic liver, familiarity with the features of HCC can facilitate noninvasive diagnosis and early and accurate treatment.

Liver fibrosis diagnosis by blood test and elastography in chronic hepatitis C: agreement or combination?

BACKGROUND: In chronic hepatitis C, the European Association for the Study of the Liver and the Asociacion Latinoamericana para el Estudio del Higado recommend performing transient elastography plus a blood test to diagnose significant fibrosis; test concordance confirms the diagnosis. AIM: To validate this rule and improve it by combining a blood test, FibroMeter (virus second generation, Echosens, Paris, France) and transient elastography (constitutive tests) into a single combined test, as suggested by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America. METHODS: A total of 1199 patients were included in an exploratory set (HCV, n = 679) or in two validation sets (HCV ± HIV, HBV, n = 520). Accuracy was mainly evaluated by correct diagnosis rate for severe fibrosis (pathological Metavir F ≥ 3, primary outcome) by classical test scores or a fibrosis classification, reflecting Metavir staging, as a function of test concordance. RESULTS: Score accuracy: there were no significant differences between the blood test (75.7%), elastography (79.1%) and the combined test (79.4%) (P = 0.066); the score accuracy of each test was significantly (P < 0.001) decreased in discordant vs. concordant tests. Classification accuracy: combined test accuracy (91.7%) was significantly (P < 0.001) increased vs. the blood test (84.1%) and elastography (88.2%); accuracy of each constitutive test was significantly (P < 0.001) decreased in discordant vs. concordant tests but not with combined test: 89.0 vs. 92.7% (P = 0.118). Multivariate analysis for accuracy showed an interaction between concordance and fibrosis level: in the 1% of patients with full classification discordance and severe fibrosis, non-invasive tests were unreliable. The advantage of combined test classification was confirmed in the validation sets. CONCLUSIONS: The concordance recommendation is validated. A combined test, expressed in classification instead of score, improves this rule and validates the recommendation of a combined test, avoiding 99% of biopsies, and offering precise staging.

Evaluation of unenhanced post-mortem computed tomography to detect chest injuries in violent death.

PURPOSE: The aim of this study was to assess the performances of unenhanced post-mortem computed tomography (CT) to detect thoracic injuries in violent death. MATERIALS AND METHODS: Retrospectively, we conducted a review of unenhanced CT scans of 67 victims of violent deaths with thoracic injuries and compared CT findings with the results of clinical autopsy. Our gold standard was a comparison of CT scans with autopsy discussed in a monthly forensic radiology multidisciplinary team meeting (MDTM). The data were collected by organ system: heart, pericardium, aorta, lungs, pleura, bone, and diaphragm and performance indices (sensitivity, specificity, accuracy) were calculated. RESULTS: Pleural (59/67) and bone (55/67) injuries detected on CT were also found at autopsy and confirmed by the MDTM (sensitivity and specificity 100%). Seventeen out of 67 diaphragmatic lesions were visible on CT. Eighteen out of 67 were confirmed during MDTM after autopsy, yielding overall sensitivity of 94% and specificity of 98%. Forty out of 67 lung contusions were found on CT with two false positives and one false negative yielding 95% sensitivity for CT with a specificity of 96%, and accuracy of 95%. Fourteen out of 67 aortic injuries were found on CT compared to 19 confirmed during MDTM (sensitivity 74%, specificity 85%, accuracy 82%). In terms of pericardial lesions, 19/67 were found on CT and 20 on autopsy and confirmed during MDTM (sensitivity 80%, specificity 94%, accuracy 85%). Ten out of 10/67 cardiac lesions were visible on CT imaging and 15 found on autopsy and confirmed during MDTM (sensitivity 57%, specificity 94%, accuracy 81%). CONCLUSION: Unenhanced post-mortem CT performs well to detect pleural, pulmonary, bone and diaphragmatic injuries but less well to identify cardiac and aortic injuries, for which the use of indirect signs is essential.

[Mangafodipir trisodium-enhanced magnetic resonance cholangiography for detection of bile leaks]. / Intérêt de l'IRM avec perfusion de mangafodipir trisodium dans la détection des fuites biliaires.

PURPOSE: To assess the value of contrast-enhanced magnetic resonance cholangiography with Teslascan perfusion for the detection and localization of trauma-induced and postoperative bile leaks. MATERIALS AND METHODS: Between October 2002 and December 2004, 7 patients with suspected bile duct leaks after trauma (n = 2) or surgery (n = 5) requiring morphological evaluation were included. MRI examination included single shot fast spin- echo T2 weighted and gradient echo T1 weighted images prior to and 112 minutes in average after IV administration of mangafodipir trisodium. The results of contrast enhanced MR cholangiography were correlated to surgery (n = 3), clinical course (n = 3) and percutaneous drainage (n = 1). RESULTS: Mangafodipir trisodium-enhanced imaging showed extravasated Teslascan in collections in 6 patients (86%) whereas the combination of T2 weighted images and mangafodipir trisodium enhanced images revealed biliary collections in 7 patients (100%). The fistula between bile duct and collection was visualized in 4 patients (57%) before mangafodipir trisodium perfusion and in 3 patients (43%) after injection. In one patient the fistula was visible only after injection. Combination of both pre- and post injection MR correctly depicted the origin of bile leak in 5 cases (71%). CONCLUSION: Mangafodipir trisodium-enhanced magnetic resonance cholangiography is a non invasive technique that can successfully detect the presence of bile duct leaks. The combination of T2 weighted MR cholangiography and mangafodipir trisodium-enhanced T1 weighted MR cholangiography increases the sensitivity in detection and localization of the site of bile leak.

Percutaneous cholecystostomy for high-risk patients with acute cholecystitis.

BACKGROUND: Cholecystectomy remains the best treatment for acute cholecystitis but may cause high morbidity and mortality in critically ill or elderly patients. METHODS: From October 1995 to March 2004, percutaneous cholecystostomy was performed in 65 patients with acute cholecystitis. The mean age was 78 years (range, 45-95). All patients were American Society of Anesthesiologists (ASA) class III (n = 51) or ASA IV (n = 14). RESULTS: Percutaneous cholecystostomy was technically successful in 63 patients (97%) with no attributable mortality or major complications. In two patients, bile drainage was inefficient, requiring emergency laparoscopic cholecystectomy. One patient developed necrotic cholecystitis and died. The 30-day mortality rate was 13.8% (n = 9); eight patients died of respiratory or cardiac complications related to comorbidities. Mean drainage time was 18 days (range, 9-60). Postoperative length of hospital stay was 15 days (range, 7-30). Early and delayed cholecystitis occurred in six and five patients, respectively. During follow-up (mean, 20.4 months), five patients died of their underlying medical condition at 5, 6, 8, 12, and 14 months, respectively. In this study, delayed elective cholecystectomy was performed in 10 patients (15.3%). CONCLUSIONS: Percutaneous cholecystostomy is a valuable and effective procedure without mortality and with a low morbidity. Whenever possible, percutaneous cholecystostomy should be followed by laparoscopic cholecystectomy.

Radiological treatment of HCC: Interventional radiology at the heart of management.

Interventional radiology is involved practically at each stage in the treatment of hepatocellular carcinoma, as recommended in the EASL-EORTC guidelines. It is even becoming more important as technological advances progress and as its long-term efficacy is assessed. Used curatively, thermoablation can obtain five-year survival rates of 40 to 70%, with a survival rate of 30% at 10years. As there are many tools available in order to be used, it requires a thorough pre-treatment assessment and discussion in a multidisciplinary team meeting. Regular patient reassessment is needed in order to be able to adjust treatment because of the complementarity of the treatments available and the course of the disease.

[Percutaneous cholecystostomy for acute cholecystitis in high-risk patients]. / Cholécystostomie percutanée dans les cholécystites aiguës chez les patients à haut risque.

AIM OF THE STUDY: The aim of this retrospective study was to report the results of percutaneous cholecystostomy in a selected group of high-risk patients with contraindications of general anesthesia. PATIENTS AND METHODS: From October 1995 to December 1999, a percutaneous cholecystostomy was performed in 29 patients with acute cholecystitis. There were 20 women and nine men with a mean age of 80.6 years (range: 59 to 95 years). All the patients were ASA III (N = 23) or ASA IV (N = 6). Ultrasound-guided percutaneous cholecystostomy was performed in 24 cases and computed tomography-guided cholecystostomy in five cases. RESULTS: Percutaneous cholecystostomy was easily performed in 28 cases; there was one failed procedure. The drainage was not efficient in three patients who were operated on with one postoperative death of a patient who had a necrotic cholecystitis. There was no mortality in relation with cholecystostomy. One patient died at day 15 from myocardia infarction. The morbidity rate was 3.4% (one case). Postoperative length of hospital stay was 13 days (range: 7-30 days). The duration of the entire procedure ranged from 9 to 60 days (mean: 20 days). The mean follow-up of patients was 17 months (range: 4-40 months). One patient had recurrent acute cholecystitis and another one had angiocholitis; two patients underwent delayed elective laparoscopic cholecystectomy; 20 patients remained asymptomatic and 16 were still alive at the time of this study (13 with biliary stones and three without). CONCLUSION: Percutaneous cholecystostomy is a valuable alternative procedure for high-risk patients with acute cholecystitis. It's a safe and usually effective procedure without mortality and with a low morbidity. Whenever possible, percutaneous cholecystostomy should be followed by laparoscopic cholecystectomy.

[Percutaneous cholecystostomy in non-surgical patients]. / Cholécystostomie percutanée chez le patient inopérable.

PURPOSE: To assess the efficacy and complications of percutaneous cholecystostomy (PC) in the treatment of acute cholecystitis in non-surgical patients. MATERIALS AND METHODS: Retrospective study of 25 cases (16 males and 9 females) of PC. The average age was 82 years (range: 59-95). Eight had acute acalculous cholecystitis (AAC) and 17 had acute calculous cholecystitis (ACC). US-guided percutaneous cholecystostomy was performed in most cases; CT-guidance was required in 5 cases. RESULTS: One technical failure and one complication (abdominal wall hematoma) occurred. PC was successful for sepsis control in 21 patients (5 AAC and 16 ACC): delayed cholecystectomy was performed in one patient, and one patient had recurrent acute cholecystitis at one month that responded to medical management. For the 4 remaining patients: 1 corresponded to the technical failure, and failure of sepsis control was observed in the 3 others patients (2 AAC, 1 ACC). PC was the definitive treatment or resulted in sepsis control in 84% of cases. PC was the definitive treatment, without recurrence, in 76% of cases. CONCLUSION: US or CT guided percutaneous cholecystostomy is an effective treatment, with a low rate of complication, in elderly or critically ill patients. PC can be used as a definitive treatment or as a temporizing measure in critically ill patients allowing for delayed definitive surgical/endoscopic management.

[Value of the transgluteal approach under CT-guidance for percutaneous interventional image guided procedures]. / Intérêt de la voie d'abord transglutéale sous contrôle tomodensitométrique dans les procédures radiologiques interventionnelles percutanées.

PURPOSE: To assess the CT-guided transgluteal approach for percutaneous interventional image guided procedures. MATERIALS AND METHODS: CT guided transgluteal approach through the greater sciatic foramen was used for diagnostic procedure (CT guided needle biopsy of presacral masses n=5) or percutaneous treatment (aspiration n=4, and drainage n=10) in 19 patients, mean age 58 years (age range 20-86). RESULTS: No technical failure occurred. A histological diagnostic was obtained in all diagnostic procedures. The success rate for therapeutic procedures was 87% and allowed to postpone surgery in 2 cases. In 2 patients a small pelvic hematoma occurred after catheter placement, but remained without consequence. Recurrences of collection occurred in 2 cases, one treated medically and the other surgically. Two patients suffered from transient deep pelvic pain, which resolved after catheter removal. CONCLUSION: CT-guided percutaneous transgluteal procedures may be successfully performed in patients who cannot undergo trans-perineal, trans-rectal or trans-vaginal approach and is a safe and effective diagnostic and therapeutic option.

[Endometriotic cyst of the liver: a case report]. / Kyste endométriosique hépatique: à propos d'un cas clinique.

Hepatic endometriosis is a rare cause of complex hepatic cyst. We describe its typical imaging features. Diagnosis can be suggested at imaging but histological confirmation is required. The treatment of suspected endometriotic cyst of the liver is surgical, and percutaneous management is contraindicated.

[Preoperative evaluation of choledochal cyst with MR cholangiopancreatography]. / Bilan préthérapeutique d'une dilatation congénitale de la voie biliaire principale par cholangio-pancréatographie-IRM.

UNLABELLED: The choledochal cyst is a rare congenital disorder usually diagnosed in childhood. It requires a complete surgical resection to prevent complications, particularly the risk of malignant changes. At present, the preoperative examination requires a direct opacification of the biliary tree, but this is an invasive technique with a high risk of infection, especially in pediatric patients. CASE REPORT: A choledochal cyst was diagnosed in a five-year-old girl with recurrent abdominal pain. Diagnosis was made by ultrasound and preoperative evaluation by magnetic resonance-cholangiopancreatography using single-shot fast-spin echo sequences. A complete correlation was observed between surgical, preoperative cholangiography and MRCP data. CONCLUSION: Recent improvement in MRCP techniques provide a complete anatomic analysis of choledochal cysts, enabling one to diagnose an anomalous junction of the pancreaticobiliary duct, even the presence of stones within the biliary tree. This short and noninvasive examination should in the future replace direct opacification of the biliary tree for the preoperative assessment of choledochal cysts.

[Diagnosis and quantification of hepatic fibrosis with diffusion weighted MR imaging: preliminary results]. / Diagnostic et quantification de la fibrose hépatique par IRM de diffusion: résultats préliminaires.

PURPOSE: Diagnosis and quantification of hepatic fibrosis are especially important in patients with chronic liver disease. Liver biopsy remains the gold standard for diagnosis of cirrhosis but has several limitations. The purpose of this study was to determine the usefulness of diffusion-weighted MR imaging, for the diagnosis of cirrhosis and quantification of hepatic fibrosis, and to define the best sequence parameters for this evaluation. METHODS AND MATERIALS: Diffusion-weighted imaging using a 1.5 T MR unit was performed in 14 healthy volunteers and 13 cirrhotic patients. Sets of 8 images with different b values (200, 400, 600, and 800 sec/mm2) and different TR (3500 and 5000 ms) were acquired with breath-holding. Apparent diffusion coefficients (ADCs) were calculated. Correlation between Child-Pugh scores, serum hyaluronate concentrations and ADCs were performed. RESULTS: ADCs were significantly lower in cirrhotic patients (2,055 10-3) compared to controls (2,915 10-3) (p<0.05) when the b value was 200 s/mm2 and the TR was 5000 ms. Significant correlations were observed between Child-Pugh scores and ADCs (p<0.05), and between serum hyaluronate concentrations and ADCs (p<0.05), when the b value was 400 sec/mm2 and the TR was 5000 ms. CONCLUSION: Our preliminary study showed that the measurement of ADCs has good potential for diagnosis and quantification of hepatic fibrosis, especially when using b values of 200 sec/mm2 and 400 sec/mm2.

Technique and indications of percutaneous cholecystostomy in the management of cholecystitis in 2014.

The gold standard in treatment of acute cholecystitis is cholecystectomy associated with antibiotics. In certain circumstances, percutaneous cholecystostomy is an interventional alternative. Percutaneous cholecystostomy is usually performed under local anesthesia by the radiologist using ultrasonographic or CT guidance. A drain can be inserted either through a trans-hepatic or a trans-peritoneal approach. Complications occur in nearly 10% of cases including hemorrhage, hemobilia, pneumothorax or bile leaks, depending on whether the approach was trans-hepatic or trans-peritoneal. The main indications for percutaneous cholecystostomy are resistance to medical treatment or severely-ill patients in intensive care. Drains should be maintained 3 to 6 weeks before removal. In patients with good general condition (ASA score I-II), secondary cholecystectomy can be recommended to avoid recurrence.

Tomodensitometric survey of the distance between thoracic and abdominal vital organs and the wall according to BMI, abdominal diameter and gender: proposition of an indicative chart for the forensic activities.

INTRODUCTION: Forensic doctors are frequently asked by magistrates when dealing principally with knife wounds, about the depth of the blade which may have penetrated the victim's body. Without the use of imaging, it is often difficult to respond to this question, even in an approximate way. Knowledge of the various distances between organs and the skin wall would allow an assessment to be made of the minimum blade length required to obtain the injuries observed. The objective of this study is thus to determine average distances between the vital organs of the thorax and abdomen, and the skin wall, taking into account the person's body mass index (BMI). MATERIALS AND METHODS: This is a prospective single-center study, carried out over a 2-month period at University Hospital in Angers. A sample of 200 people was studied. The inclusion criteria were as follows: all patients coming to the radiology department and the emergency department for an abdominal, thoracic or thoraco-abdominal scan with injection. The exclusion criteria included patients presenting a large lymphoma, a large abdominal or retroperitoneal tumor, a tumor in one of the organs targeted by our study and patients presenting ascites. The organs focused on were: the pericardium, pleura, aorta, liver, spleen, kidneys, abdominal aorta and femoral arteries. The shortest distance between the organ and the skin wall was noted. Median distances were calculated according to gender, abdominal diameter and BMI. RESULTS: We associated these values to propose an indicative chart which may be used by doctors in connection with their forensic activities. DISCUSSION: The problem of the depth of a wound is frequently exposed to the expert. Without a reliable tool, it is difficult to value and a personal interpretation is often done. Even if, in current days, tomodensitometry is frequently done in vivo or after death, measurement can be difficult because of the local conditions. We classified values according to the different factors of fat repartition (BMI, abdominal diameter, gender). These tables, collectively used, permit evaluation of the distance between wall and thoracic or abdominal vital organs. CONCLUSION: We suggest an indicative chart designed for forensic doctors in their professional life to help determine the minimum penetration length for a knife, which may wound a vital organ.