ESGAR consensus statement on the imaging of fistula-in-ano and other causes of anal sepsis.

OBJECTIVES: To develop imaging guidelines for patients with fistula-in-ano and other causes of anal sepsis. METHODS: An expert group of 13 members of the European Society of Gastrointestinal and Abdominal Radiology (ESGAR) used a modified Delphi process to vote on a series of consensus statements relating to the imaging of patients with potential anal sepsis. Participants first completed a questionnaire to gather practice information and to help frame the statements posed. RESULTS: In the first round of voting, the expert group scored 51 statements of which 45 (88%) achieved immediate consensus. The remaining 6 statements were redrafted following input from the expert group and consensus achieved for all during a second round of voting, including an additional statement drafted. No statement was rejected due to a lack of consensus. After redrafting to improve clarity, 53 individual statements were presented. CONCLUSION: These expert consensus statements can be used to guide appropriate indication, acquisition, interpretation and reporting of medical imaging for patients with potential fistula-in-ano and other causes of anal sepsis. KEY POINTS: • Medical imaging, notably magnetic resonance imaging, is used widely for the diagnosis and monitoring of fistula-in-ano and other causes of anal and perianal sepsis. • While the indexed medical literature is clear that diagnostic accuracy is potentially excellent, this depends on competent image acquisition and interpretation. • In order to facilitate this, the European Society of Gastrointestinal and Abdominal Radiology (ESGAR) has produced expert consensus guidelines regarding the imaging of fistula-in-ano and related conditions.

Value of T2-weighted magnetic resonance imaging in the assessment of wall inflammation and fibrosis in Crohn's disease.

This review focuses specifically on the diagnostic value of T2-weighted imaging in the assessment of Crohn's disease (CD) inflammation. In general, T2-weighted imaging has been less extensively investigated than T1-weighted gadolinium-enhanced imaging, even if it may offer similar information on disease activity. Furthermore, T2-weighted imaging allows CD characterization, which is crucial in the management of the disease when differentiating intestinal edema from fibrosis. Technical aspects, morphological findings and signs of active intestinal inflammation and fibrosis detectable on T2-weighted images will be reviewed and shown. Correlation between T2-weighted imaging findings, clinical activity indexes and histopathology features will be discussed. Since T2-weighted imaging is essential in the evaluation of CD activity, it should always complement with T1-weighted imaging, although it could also be used alone in the assessment of CD.

Surveillance of patients affected by Peutz-Jeghers syndrome: diagnostic value of MR enterography in prone and supine position.

INTRODUCTION: Peutz-Jeghers syndrome (PJS) is a familial polyposis syndrome characterized by multiple hamartomatous polyps throughout the gastrointestinal tract. The aim of our study was to retrospectively determine the diagnostic value of MR enterography (MRE), performed in supine and prone position, in the detection of small bowel polyps in PJ patients. MATERIALS AND METHODS: We retrospectively reviewed MRE examinations of 8 PJS patients who underwent MRE, pushed-double-ballon enteroscopy, laparoscopic endoscopy or surgery, within 3 months. Polietilenglicole was orally administered before the examination. True FISP and HASTE sequences were acquired in supine and prone position; 3D VIBE Gd-enhanced sequences in prone position only. RESULTS: Concordance between MRE and endoscopy was 72.6% for polyps <15 mm, 93% for polyps >15 mm. In supine and prone position concordance with endoscopy for polyps <15 mm was 63% and 66.8%, respectively. In the detection of smaller polyps the difference between supine position only and supine plus prone position was statistically significant (P < 0.027). DISCUSSION: MRE performed by combining prone and supine position was accurate in the detection of PJS polyps, with 93% concordance with enteroscopy for larger and more risky polyps. MRE offers a promising and non invasive alternative to capsule endoscopy, suggesting the possibility of an effective yearly surveillance in PJ patients.

Clostridium difficile-related pancolitis in lung-transplanted patients with cystic fibrosis.

C. difficile (C. d.) is the main cause of antibiotic-associated diarrhea and colitis. It is shown in literature a high asymptomatic carriage rate of C. d. in patients with cystic fibrosis (CF), though C. d.-related colitis is an uncommon complication in these patients, despite the use of multiple high-dose antibiotic regimes and the frequency of hospital admissions. Lung transplantation with the associated immunosuppression and aggressive antibiotic therapy may increase the risk of the clinical manifestation of C. d. In this paper, we describe three cases of severe C. d. colitis in patients with CF following lung transplantation and illustrate our experience in the diagnosis and management of these patients.

Magnetic resonance cholangiography: past, present and future: a review.

INTRODUCTION: Magnetic resonance cholangio-pancreatography (MRCP) is a valuable method for the evaluation of biliary and pancreatic diseases and a valuable alternative to endoscopic retrograde cholangiopancreatography (ERCP). It is noninvasive and does not require the use of contrast material or ionizing radiation. Since its introduction in 1991, this technique has significantly improved in spatial resolution, now allowing the accurate assessment of the major bilio-pancreatic diseases. STATE OF THE ART: MRCP is commonly performed with heavily T2-weighted sequences in order to highlight static fluids, as those contained in dilated pancreatic and biliary ducts. Newest MR equipments allow to perform MRCP within 10-15 minutes, due to the availability of ultra-fast sequences. Currently, MRCP is widely performed as a primary imaging modality for the assessment of obstructive jaundice and other benign or malignant bilio-pancreatic ducts abnormalities. The primary MRCP application is the evaluation of biliary obstructions due to choledocholithiasis, iatrogenic strictures, cholangiocarcinoma or pancreatic carcinoma. Other MRCP applications include the assessment of the exocrine pancreatic function, following secretin stimulation. Whenever needed, the MRCP may be completed with a conventional contrast-enhanced magnetic resonance imaging (MRI) of the upper abdomen and functional studies as well, thus providing an all-in-one mophological and functional study of the pancreas and biliary system. More recent applications include the possibility of 3D reconstructions and the use of hepato-biliary contrast agents, that provide a higher definition of the biliary tree, both in pathologic and normal conditions. The introduction of 3Tesla magnets could provide higher anatomic detail. CONCLUSIONS: In the next years the role of MRCP will further expand, due to the availability of faster sequences, 3D imaging and functional studies.

Diffuse abdominal hydatidosis: role of magnetic resonance imaging.

Hydatid cyst disease still is a serious public-health problem in endemic areas. It is a tissue infestation caused by the larval stage of a parasite, Echinococcus granulosus. Although liver and lung are the most commonly involved organs, hydatid disease can occur in all viscera and soft tissues. In 10% of cases, hydatid disease arises in the viscera: mainly in the spleen (0.9-8%), but also in kidney, bone, heart and peritoneal cavity (0.5-5%). Other rare locations such as muscles have been described in less than 1% of cases of hydatid disease. We report magnetic resonance imaging findings of a case of diffuse abdominal hydatidosis.

[Magnetic resonance and traditional radiology in the spine localizations of alkaptonuric ochronotic arthropathy]. / Risonanza magnetica e radiologia tradizionale nelle localizzazioni vertebrali dell'artropatia ocronotica alcaptonurica.

AIM: To study the spine alterations in alcaptonuria with traditional radiology and magnetic resonance (MR), comparing the results of the two techniques. PATIENTS AND METHODS: Five patients (4 males, 1 female, mean age 51 years) underwent the examinations. For the study with X-rays we performed anteroposterior and lateral scan and the images have been studied making reference to a radiographic score; it examines the alterations of the joint space and the presence of calcifications. MR scan, oriented in the three spatial planes, were performed using spin echo T1-weighted and spin echo T2-weighted sequences. RESULTS: Both MR and X-rays pointed out, in the cases with known diagnosis, the typical alterations of the ochronosis: narrowing of the articular spaces, even osseous ankylosis, calcifications of the discs, osteophytosis, multiple disc protrusions and reactive sclerosis of the articular surfaces, evident above all to dorso-lumbar tract; nevertheless MR has been more accurate than X-rays for individualizing the lesions and recognizing alterations, such as the thickness of the anterior longitudinal ligament. In the case of new diagnosis, the MR is fundamental to recognize typical signs of the ochronotic arthropathy not well detected by X-rays. CONCLUSIONS: Imaging techniques, first of all the MR, are essential in the differential diagnosis of ochronosis vertebral lesions with other articular diseases.

Effect of the chest wall and blood volume on pulmonary distensibility.

To determine the reason for increased pulmonary distensibility in excised lungs, we performed deflation pressure-volume (PV) studies in 24 dogs. Exponential analysis of PV data gave K, an index of distensibility. Lung volume was measured by dilution of neon. Compared with measurements obtained in the supine position, with the chest closed, and with esophageal pressure (Pes) to obtain transpulmonary pressure, K was not changed significantly with the chest strapped, with pleural pressure to obtain transpulmonary pressure, or with the chest open. From displacement of PV curves obtained in the supine position and with the chest closed or open, we estimated that Pes was 0.18 kPa greater than average lung surface pressure. An increase in K in the prone and head-up positions was attributed to a traction artifact decreasing Pes. Exsanguination increased K and produced a relative increase in gas volume. These results show that overall pulmonary distensibility is unaffected by an intact chest wall. An increase in K and gas volume after exsanguination probably reflects a decreased pulmonary blood volume, with collapse of capillaries increasing the alveolar volume-to-surface ratio.

Characterisation of human lung elastin-derived peptides.

The enzymatic breakdown of human lung elastin by leukocyte elastase precedes the development of pulmonary emphysema, and releases elastin-derived peptides (EDPs) into the circulation. While raised levels of EDPs measured by enzyme-linked immunosorbent assay (ELISA) have been proposed as a possible marker for early detection of emphysema, average normal values of EDPs measured by different investigators have differed by up to a factor of 1000. Standardisation of the methodology for elastin purification and EDP production in vitro is required to ensure the accuracy of EDP measurements in vivo, because antiserum used in the ELISA is raised against the EDPs produced in vitro. In the present study elastin was purified from human lung by sequential biochemical extraction, and solubilised by leukocyte elastase. Molecular weight distribution of EDPs produced by partial and complete elastin digestion were compared by gel exclusion chromatography. A method for successful separation of EDPs by SDS-polyacrylamide gel electrophoresis (SDS-PAGE) is reported. The implications of these results for further immunological characterisation of these peptides are discussed with a view to standardisation of the techniques employed for the measurement of EDPs in vivo.

Endocrine tumors of the pancreas.

We have described the clinical presentation of the commonest syndromes associated with hormone production by functioning pancreatic tumors. The role of the radiologist in tumor localization, staging, and treatment is discussed and the various imaging methods employed are examined individually. The problems of reviewing the world literature on such rare lesions are discussed and a tentative diagnostic algorithm is suggested.

Adenocarcinoma on horseshoe kidney studied with computed tomography.

Horseshoe kidney is a congenital anomaly of the upper urinary system frequently associated with atypical vascularization, mostly asymptomatic, usually undetected until the onset of infectious, obstructive or neoplastic complications. Although intravenous pyelography and US are useful tools, the role of CT is of vital importance especially in the pre-operative planning of related complications and in those cases where other techniques have correctly diagnosed the disease but have missed the visualization of an underlying malformation. We report here two cases of adenocarcinoma in two patients with a horseshoe kidney, where CT has clearly depicted both the malformation and the associated pathologic findings.

Extraskeletal myxoid chondrosarcoma of the thoracic wall.

The authors report the CT features of a very rare case of Extraskeletal Myxoid Chondrosarcoma of the thoracic wall, one of a few malignant primary bone tumors which rarely originate from soft tissues.

CT cystoscopy in the evaluation of bladder tumors.

The aim of the present study was to assess the role of virtual cystoscopy in the identification of bladder tumors. Fifteen patients (11 men and 4 women, median age: 61 years, range: 46-74 years) with a positive finding of bladder tumor at fiber-optic cystoscopy were studied by multislice-CT. Scans were downloaded to a workstation with the aid of a software for the processing of 3-D reconstructions, with a volume-rendering technique which allowed the "navigation" within the bladder in search of wall lesions. In this group of 15 patients, cystoscopy was able to detect 19 neoplastic lesions, 13 with a diameter >10 mm and 6 with a diameter <10 mm. Virtual cystoscopy, instead, identified 17 lesions (89%) only. In particular, all those lesions with a diameter >1 cm (13/13=100%) were correctly identified, whereas only 4 of the 6 lesions with a diameter <1 cm were depicted. The 2 false negative cases were 2 lesions with a flat morphology, measuring 5 and 6 mm. Most recent technological advances allowed the employement of virtual endoscopies, characterized by the absence of invasivity as compared with fiber-optic studies and based on data obtained by spiral- and multislice-CTs. According to our experience, virtual CT-cystoscopy revealed to be a complementary tool in the evaluation of cross-sectional images and proved to be an easy procedure without complications, well-accepted by the patients, and with a reliable detection of those bladder lesions measuring more than 5 mm in case of polypoid formations and at least 10 mm in case of flat lesions. This technique, however, does not allow the collection of a bioptic sample and--with the present resolution power of available equipments--it could be unable to correctly detect small-sized flat lesions. We, nonetheless, believe that this procedure, in the future, thanks to rapid technological improvements in virtual imaging techniques, could become a useful diagnostic tool in the management of those patients with bladder tumors. Further studies on larger study groups are therefore desirable for a more reliable validation of the technique.

Behaviour of Cd, Cr, Mn, Ni, Pb, and Zn in sewage sludge incineration by fluidised bed furnace.

Cd, Cr, Mn, Ni, Pb, and Zn behaviour during sewage sludge incineration was investigated in seven pilot tests using a circulating fluidised bed furnace. Dewatered sludge at a solids concentration of 15-18% was fed to the furnace either alone (two tests) or spiked with chlorinated organic compounds (five tests). The behaviour of metals in the fluidised bed furnace was studied by comparing metal concentrations in the two main ash streams: ash separated from the cyclone immediately following the fluidised bed furnace, and fly ash recovered in the final bag filter. A metal enrichment factor was defined as the ratio of metal concentration between filter ash and cyclone ash. Only Cd and Pb showed any significant enrichment. Their enrichment factors were mainly affected by chlorine concentration in the feed sludge. To check whether simple equilibrium models may explain and predict metal behaviour, experimental data were compared with percentage of the metal vaporisation in the combustion chamber predicted using a thermodynamic model. Discrepancies between model predictions and experimental results are accounted for by considering that kinetics may be a limiting factor in the formation of metal chloride gaseous species. Due to the very short sludge residence time in the fluidised bed furnace, the gaseous compounds have little chance to evolve completely.

[Magnetic resonance of the knee: possibility and current indications]. / La risonanza magnetica del ginocchio: possibilità ed indicazioni attuali.

MRI is a multiparametric, multiplanar, non-invasive largely employed tool for assessing osseous, ligamentous and tendineous injuries, inflammatory and degenerative changes of the knee. Although its wider availability and the lack of ionizing radiations MRI should be used only if clinically useful in patient management, in a appropriate diagnostic iter including plain film and/or ultrasound examination. The aim of our work is to review possibilities, limits and current indications for MRI assessment of diseases of the knee.

[Leiomyosarcoma in jejunal diverticulum. A case report and review of the literature]. / Leiomiosarcoma in diverticolo digiunale. Presentazione di un caso e revisione della Letteratura.

The Authors describe a case of double jejunal diverticulum, characterized by the presence of a leiomyosarcoma in one diverticulum and ectopic pancreatic mucosa in the other. The rarity of the occurrence of a leiomyosarcoma in the diverticular area is outlined; only few cases have been reported in Literature, excluding those originating, from Meckel's diverticulum. Barium X-rays of the small intestine allowed the neoplasia to be discovered, while an Echo-Color-Doppler examination suggested the histological type given the high vascularization typical of leiomyosarcomas.

[Diagnosis and treatment of distal bile duct carcinoma: our experience]. / Diagnosi e trattamento delle neoplasie del coledoco distale: nostra esperienza.

Bile duct carcinomas are known to be difficult to cure, due to frequent locoregional recurrence even after radical resection. The Authors analyze their experience in a study about 53 patients treated between October 1991-January 2002.

[Collateral effects of intraoperative hyperthermic chemotherapy in peritoneal carcinomatosis]. / Effetti collaterali della ipertermochemioterapia intraoperatoria nel trattamento della carcinosi peritoneale.

The association between chemotherapy and hypertermia produces a synergic effect. In this study the Authors present their experience, by the analysis of the results. From 1993 to 2000, 17 patients have been treated with surgery associated with hypertermic chemotherapy for peritoneal carcinomatosis. For the management of these patients a constant cooperation among surgeon, cardiologist and anaesthetist is very important.

Imaging techniques for assessment of inflammatory bowel disease: joint ECCO and ESGAR evidence-based consensus guidelines.

The management of patients with IBD requires evaluation with objective tools, both at the time of diagnosis and throughout the course of the disease, to determine the location, extension, activity and severity of inflammatory lesions, as well as, the potential existence of complications. Whereas endoscopy is a well-established and uniformly performed diagnostic examination, the implementation of radiologic techniques for assessment of IBD is still heterogeneous; variations in technical aspects and the degrees of experience and preferences exist across countries in Europe. ECCO and ESGAR scientific societies jointly elaborated a consensus to establish standards for imaging in IBD using magnetic resonance imaging, computed tomography, ultrasonography, and including also other radiologic procedures such as conventional radiology or nuclear medicine examinations for different clinical situations that include general principles, upper GI tract, colon and rectum, perineum, liver and biliary tract, emergency situation, and the postoperative setting. The statements and general recommendations of this consensus are based on the highest level of evidence available, but significant gaps remain in certain areas such as the comparison of diagnostic accuracy between different techniques, the value for therapeutic monitoring, and the prognostic implications of particular findings.

Correlation between faecal calprotectin and magnetic resonance imaging (MRI) in the evaluation of inflammatory pattern in Crohn's disease.

BACKGROUND: Calprotectin, a major cytosolic protein of neutrophils, is increased in inflammatory bowel disease (IBD) and may be considered a suitable marker of intestinal inflammation. Abdominal MRI is becoming more frequently used for the evaluation of IBD patients. Aim of this study was to investigate the role of MRI in IBD for the assessment of disease activity in comparison with faecal calprotectin levels. PATIENTS AND METHODS: Twenty-four consecutive hospitalized pts (12 F, 12 M, median age: 56; range: 22-77) with a proven diagnosis of CD were studied. At the time of the MRI examination, pts provided a single stool sample for calprotectin measurement. Calprotectin was measured by ELISA (Calprest(R)). Pathological values were considered more than 50 microg/g. All pts underwent MRI, performed at 1.5 T, with HASTE T2w with and without fat-saturation, FLASH T1w fat-saturated sequences pre and post iv injection of 0.1 ml/kg of Gadolinium. Presence, degree and length of wall inflammation were evaluated. The MRI degree of wall inflammation was graded with a 0-3 scoring system (0=absent 1=light 2=moderate 3=severe) by considering findings observed on T1 post Gd and T2 fat-suppressed images, as well as the degree of wall thickness. The length of extension was considered as less than 15 cm, between 15 cm and 30 cm, or more than 30 cm. Spearman's correlation coefficient was used to evaluated differences in calprotectin levels among the groups obtained by MRI findings. RESULTS: Grade 0 MRI was found in 1 pt with a faecal calprotectin measurement of 206.25 microg/g; Grade 1 MRI was found in 4 pts with a median faecal calprotectin of 100 microg/g (5-325); Grade 2 MRI was found in 10 pts with a median faecal calprotectin of 243.75 microg/g (7.5-606.25); Grade 3 MRI was found in 9 pts with a median faecal calprotectin of 1012.5 microg/g (30-1268.8). A trend of positive correlation was therefore found between MRI scores of activity and calprotectin levels (p less than 0.0001) and between MRI scores of thickening of intestinal involvement and calprotectin levels (p = 0.005). No apparent correlation was observed between faecal calprotectin concentration and length. CONCLUSIONS: Data presenting show that faecal calprotectin levels well correlate with the degree of mucosal inflammation are in agreement with previous studies. Considering the correlation obtained between calprotectin level and MRI findings, we believe that MRI is helpful in assessing and monitoring the degree of disease in Crohn's disease.