Hepatobiliary complications of inflammatory bowel disease.

A variety of biliary and hepatocellular diseases occur with increased incidence in patients with inflammatory bowel disease. These include fatty infiltration of the liver, cholelithiasis, pericholangitis-primary sclerosing cholangitis, cirrhosis, chronic active hepatitis, liver abscess, amyloidosis, granulomatous hepatitis, and bile duct carcinoma. Radiography is essential in accurate diagnosis.

Value of pneumoperitoneum in the diagnosis of visceral perforation.

The presence or absence of pneumoperitoneum may not be as reliable an indicator of visceral perforation as commonly thought. Visceral perforation as commonly thought. Visceral perforation resulted in pneumoperitoneum in only 51 percent of patients in this study. Pneumoperitoneum occurred in 14 percent of patients in whom the extraalimentary intraperitoneal air had sources other than a perforated viscus. These patients' clinical findings were often indistinguishable from those of patients with a perforated viscus, and three patients underwent celiotomy unnecessarily. The routine use of the left lateral decubitus film to detect pneumoperitoneum and the judicious use of gastrointestinal contrast studies should be part of the optimal management of patients with suspected visceral perforation.

Time versus density enhancement of liver, spleen, and great vessels following rapid intravenous infusion of perflubron emulsion.

RATIONALE AND OBJECTIVES: We studied hepatosplenic enhancement in rhesus monkeys for 5 hr after rapid administration of perflubron (perfluorooctyl bromide [PFOB]) in an attempt to determine a clinically useful imaging window. METHODS: Five rhesus monkeys were examined using perflubron emulsion, 90% w/v perfluorochemical administered intravenously at a dose of 1.5 ml/kg and rate of 0.5 ml/sec. Helical computed tomography examination of the abdomen was obtained prior to the contrast bolus and 5 min, 30 min, 1, 2, 3, 4, and 5 hr postcontrast. Mean density of liver, spleen, and aorta was measured at each time interval. RESULTS: Significant aortic enhancement of 53 +/- 7 Hounsfield units (HU) (p < .0001) and liver enhancement of 19 +/- 4 H (p < .0004) occurred after 5 min and did not change significantly (p > .05) over 5 hr. Splenic enhancement of 35 +/- 9 HU was significant at 5 min (p < .0001) and continued to increase for 5 hr. CONCLUSION: Enhancement of the liver, blood vessels, and spleen is rapid and persists for at least 5 hr, which suggests a wider temporal window for hepatosplenic imaging with perflubron than is currently available with iodinated contrast agents.

Perfluoroctyl bromide as a blood pool contrast agent for computed tomographic angiography.

RATIONALE AND OBJECTIVES: We determined whether perfluoroctyl bromide (perflubron) could be used as a computed tomography (CT) angiographic agent by studying vessel visibility (celiac artery, superior mesenteric artery [SMA], and renal arteries) with spiral CT and three-dimensional (3D) reconstructions. METHODS: Five rhesus monkeys were examined with a perflubron emulsion (90% [w/v] perfluorochemical; administered intravenously at a dose of 1.5 ml/kg and at a rate of 0.5 ml/sec. Spiral CT was performed immediately and at 5 hr after injection. Three dimensional images of the aorta at the level of the celiac artery, SMA, and renal arteries were reconstructed and blindly rated 0-4 (0 = not seen; 4 = excellent visualization) by two observers. RESULTS: All the vessels had the best ratings immediately after injection: celiac artery, 2.8 +/- 0.42; SMA, 2.7 +/- 0.48; left renal artery, 2.1 +/- 0.99; and right renal artery, 1.2 +/- 1.03. The ratings after the 5-hr delay were as follows: celiac artery, 1.3 +/- 1.34; SMA, 1.5 +/- 1.08; left renal artery, 1.5 +/- 0.97; and right renal artery, 1.2 +/- 0.79. CONCLUSIONS: Spiral CT angiography with a perflubron emulsion successfully demonstrated all vessels immediately and at 5 hr after contrast agent infusion. Further refinements of the dose, rate, and reconstruction technique are expected to increase vessel visibility over this wide imaging window.

Recognition and prevention of barium enema complications.

The barium enema is a safe and accurate diagnostic study of the colon but, in rare cases, complications may result. Many of these can be prevented by proper equipment and careful attention to technique. When a complication does occur, prompt recognition and management is vital in decreasing morbidity and mortality. Perforation of the bowel is the most frequent serious complication, occurring in approximately 0.02% to 0.04% of patients. Rarely the colon may burst due to excessive transmural pressure alone. However, a colon weakened by iatrogenic trauma or disease is more likely to perforate during an enema than is a normal healthy bowel. Injury to the rectal mucosa or anal canal due to the enema tip or retention balloon is probably the most common traumatic cause of barium enema perforation. Inflation of a retention balloon within a stricture, neoplasm, inflamed rectum, or colostomy stoma is particularly hazardous. Recent deep biopsy or polypectomy with electrocautery makes the bowel more vulnerable to rupture. The tensile strength of the bowel wall is impaired in elderly patients, patients receiving long-term steroid therapy, and in disease states including neoplasm, diverticulitis, inflammatory bowel disease, and ischemia. Intraperitoneal perforation leads to a severe, acute peritonitis with intravascular volume depletion. The ensuing shock may be rapidly fatal. Prompt fluid replacement and laparotomy are essential. If the patient survives the initial shock and sepsis, later complications caused by dense intraperitoneal adhesions may develop. Extraperitoneal perforation is usually less catastrophic but may result in pain, sepsis, cellulitis, abscess, rectal stricture, or fistula. Intramural extravasation often forms a persistent submucosal barium granuloma which may ulcerate or be mistaken for a neoplasm. The most dramatic complication of barium enema is venous intravasation of barium. Fortunately, this is quite rare as it may be immediately lethal. Most cases have been attributed to trauma from the enema tip or retention balloon, mucosal inflammation, or misplacement of the tip in the vagina. Bacteremia has been found in as many as 23% of patients following barium enema and, in rare cases, may cause symptomatic septicemia. Other less common complications include barium impaction, water intoxication, allergic reactions, and cardiac arrhythmias. Preparatory laxatives and cleansing enemas have been implicated in some instances of dehydration, rectal trauma, water intoxication, and perforation. Careful review of the indications for examination, previous radiographs, and clinical history will identify many of the patients at greater risk for complications so that appropriate precautions may be observed.(ABSTRACT TRUNCATED AT 400 WORDS)

Double versus single contrast gastrointestinal radiology.

With experience, air contrast examination of the esophagus, stomach, and duodenum can be performed routinely as quickly and easily as the standard UGI. The air contrast examination is superior for detection of small gastric polyps and the Japanese have found it superior for detection of early carcinoma. The postoperative stomach and the fundus and cardia are most easily examined by air contrast. Clear superiority in the diagnosis of peptic ulcers and peptic esophagitis has not been proved. The most accurate routine examination may be a multiphasic or combined approach utilizing air contrast views as well as filled compression views and careful fluoroscopy. With respect to the colon, we do not suggest that air contrast BE must be done exclusively. However, it is superior for the detection of polyps and small carcinomas. The technique should be available in all radiology departments and should be an integral part of the evaluation of patients at increased risk of developing carcinoma. This includes patients over 40 years of age, with chronic ulcerative colitis, familial multiple polyposis or Gardner's syndrome, family history of inherited cancer, and medical history of adenomatous polyps, colorectal cancer, or female genital cancer. In addition, air contrast enema should be utilized for the sensitive and accurate evaluation of early inflammatory bowel disease. Finally, with respect to the colon examination one fact must be stressed. Irregardless of full column or air contrast method, most missed lesions are due to poor bowel preparation, poor technique, or perceptive error by the radiologist. There can be no substitute for a clean colon, meticulous attention to technical details, and careful review of the radiographs.

Retrocecal appendicitis presenting with air in the subhepatic space.

Two cases of perforated retrocecal appendicitis presenting with the roentgen finding of an air containing subhepatic abscess are discussed. Although it is an unusual cause for air in the right subhepatic space, retrocecal appendicitis should be considered in the radiologist's differential diagnosis.

Bile duct carcinoma associated with chronic ulcerative colitis.

Patients with chronic ulcerative colitis are prone to a variety of liver disorders. This case report illustrates development of bile duct carcinoma in a patient with long-standing inactive colitis. The report emphasizes the association of chronic ulcerative colitis with bile duct carcinoma and discusses the radiologic preoperative evaluation of the ulcerative colitis patient who develops jaundice.

The radiology corner. Is an air-fluid level within a gastric ulcer a reliable roentgen sign of benignancy?

A review of 108 cases of benign gastric ulcers and 33 ulcerated malignant gastric neoplasms showed that air-fluid levels were present within 25 benign ulcers and in only one malignant ulcer. These differences are statistically significant. Since, however, in unusual circumstances, a malignant ulcer may contain an air-fluid level, use of this roentgen sign alone to determine benignancy is not recommended. If used in conjunction with other accepted roentgen criteria, the presence of an air-fluid level within a gastric ulcer substantiates the diagnosis of benignancy in the majority of cases.

Preliminary abdominal films in oral cholecystography: are they necessary?

A survey of 45 radiologists with a special interest in gastrointestinal radiology showed that only 8% used a preliminary abdominal film for oral cholecystography. Review of 467 cases of oral cholecystography with preliminary films over a 1 year period disclosed 88 confirmed cases of cholelithiasis. Of these 88 cases, 27% had opaque gallstones visible on the preliminary film. In one-third of the cases, the opaque gallstones had a classic diagnostic appearance, while the remainder required oral cholecystography for confirmation. Opaque calculi were obscured by oral contrast material in 2% of cases. Other significant pathology on the preliminary films was found in 5.5% of the 467 cases.

Cholelithiasis in children.

Review of 367 cases of cholelithiasis in children from the literature and our experience showed that 81% of these patients has no evidence of hemolytic anemia. Oral cholecystograms were diagnostic of cholelithiasis in approximately 70% of these cases. Plain film studies were found to be of diagnostic value as a high percentage of gallstones were visible on plain radiographs of the abdomen.

MRI-compatible audio/visual system: impact on pediatric sedation.

BACKGROUND: While sedation is necessary for much pediatric imaging, there are new alternatives that may help patients hold still without medication. OBJECTIVE: We examined the effect of an audio/visual system consisting of video goggles and earphones on the need for sedation during magnetic resonance imaging (MRI). MATERIALS AND METHODS: All MRI examinations from May 1999 to October 1999 performed after installation of the MRVision 2000 (Resonance Technology, Inc.) were compared to the same 6-month period in 1998. Imaging and sedation protocols remained constant. Data collected included: patient age, type of examination, use of intravenous contrast enhancement, and need for sedation. The average supply charge and nursing cost per sedated patient were calculated. RESULTS: The 955 patients from 1998 and 1,112 patients from 1999 were similar in demographics and examination distribution. There was an overall reduction in the percent of patients requiring sedation in the group using the video goggle system from 49 to 40% (P < 0.001). There was no significant change for 0-2 years (P = 0.805), but there was a reduction from 53 to 40% for age 3-10 years (P < 0.001) and 16 to 8% for those older than 10 years (P < 0.001). There was a 17% decrease in MRI room time for those patients whose examinations could be performed without sedation. Sedation costs per patient were $80 for nursing and $29 for supplies. CONCLUSION: The use of this video system reduced the number of children requiring sedation for MRI examination by 18%. In addition to reducing patient risk, this can potentially reduce cost.

Hodgkin's disease of the rectum.

In a rare case of Hodgkin's disease of the rectum, plain films of the abdomen revealed splenomegaly, and fluoroscopy demonstrated anterior displacement of the stomach and duodenum, believed to be secondary to enlarged lymph nodes. Fluoroscopic examination of the colon showed a large, annular constricting lesion with nodular-appearing mucosa.

Gray scale ultrasonography of the gallbladder: an evaluation of accuracy and report of additional ultrasound signs.

Ultrasound examinations of 76 patients with suspected gallbladder disease were compared with radiographic, surgical, and pathologic findings to determine the accuracy of the ultrasound examinations. In 13 of the 76, the gallbladder was not visualized by ultrasound. Diagnosis of the presence or absence of gallstones was correctly made by ultrasound in 56 of 63 visualized gallbladders, for an accuracy rate of 89%. A high proprtion of nonvisualized gallbladders (10 or 13) contained gallstones. Previously unreported ultrasound findings of a stone impacted in the proximal cystic duct and findings of a collection of bile in the lesser sac associated with cholelithiasis and choledocholithiasis are illustrated.

The hamartomatous polyposis syndromes: clinical and radiologic features.

Most radiologists are familiar with the clinical and radiologic features of the familial adenomatous polyposis syndromes [1]. The hamartomatous polyposis syndromes occur less frequently, however, and their radiologic and clinical manifestations are not as well known. This group of syndromes includes Peutz-Jeghers, multiple hamartoma, juvenile polyposis, Cronkhite-Canada, and Bannayan-Riley-Ruvalcaba. The predominant gastrointestinal lesion in these diseases is some form of hamartomatous polyp. The term hamartoma implies a nonneoplastic tumor or tumorlike condition composed of tissue elements normally present in the particular area [2]. In many of these syndromes, it is now recognized that hamartomatous polyps of the gastrointestinal tract coexist with adenomas and that adenomas may develop within hamartomatous polyps. Either situation may contribute to the frequent association of alimentary tract adenocarcinoma that occurs in most of these syndromes. Various types of benign mucocutaneous lesions are common and often lead to the correct diagnosis. Of greater importance is the frequent occurrence of other extraintestinal manifestations, including several forms of malignant disease. Because of this frequent association with both gastrointestinal and nongastrointestinal malignant tumors, early and accurate diagnosis of these syndromes is essential. Meticulously performed double contrast studies are the preferred radiologic procedures for the diagnosis of gastrointestinal polyps in all of these diseases.

Recurrent tumor after resection of hepatic metastases from colorectal carcinoma: location and time of discovery as determined by CT.

OBJECTIVE: Despite studies showing increased survival rates for patients after surgical resection of hepatic metastases, recurrences occur in 75% of treated patients. The purpose of this study was to determine the location and time of discovery of recurrent tumor on CT scans after resection of hepatic metastases from colorectal carcinoma. MATERIALS AND METHODS: In a 6-year period, 32 patients (16 men and 16 women) who had undergone partial hepatic resection for colorectal metastases had follow-up CT at our institution. A total of 125 CT examinations of the chest and abdomen were retrospectively reviewed for the presence and location of recurrent disease. Recurrence was either confirmed by biopsy (n = 12) or presumed on the basis of growth of new lesions (n = 17). RESULTS: With a mean follow-up of 22 months (range, 1-60 months), recurrence was found at 29 sites in 25 patients. Thirteen sites were hepatic, and 16 were extrahepatic. Three patients had both hepatic and pulmonary disease. Recurrence within the liver was away from surgical margins in 11 (85%) of 13 patients at 14 +/- 7 months and adjacent to a surgical margin in the remaining two patients (15%) at 17 +/- 1 months. Extrahepatic recurrences were discovered in the lung in 11 (69%) of 16 patients at 21 +/- 12 months; in an adrenal gland in two patients (13%) at 19 +/- 5 months; in lymph nodes of the porta hepatis in one patient (6%) at 11 months; at the primary colonic anastomosis in one patient (6%) at 3 months; and in a retroperitoneal lymph node in the remaining patient (6%) at 12 months. CONCLUSION: Surgery was effective in treating the preoperatively detected hepatic metastases. Only two of 25 patients had recurrence related to a hepatic surgical margin. Most recurrences occur more than 1 year after surgery, most often in lung or liver away from surgical margins, and they probably represent small metastases undetectable with current preoperative or intraoperative techniques.

Inflammatory fibroid polyps of the gastrointestinal tract: radiologic evaluation.

Inflammatory fibroid polyps (IFPs) are uncommon lesions of the gastrointestinal tract. Only scattered case reports have appeared in the radiology literature. The authors reviewed the cases of 33 patients (20 women and 13 men; average age, 45 years) to determine if these polyps had any distinctive diagnostic radiologic features. The IFPs were located in the stomach (n = 16), small bowel (n = 13), and colon (n = 4). The lesions originated in the submucosa and were composed of fibroblasts, inflammatory cells, and a network of blood vessels. Gastric IFPs were most often located in the antrum and were usually ulcerated. Most of the patients presented with clinical evidence of gastrointestinal blood loss. Small bowel polyps were usually located in the ileum, and patients were typically older women with intestinal obstruction due to intussusception. Most of the lesions appeared as large, intramural masses at radiologic examination. Some of the lesions were pedunculated, and all were solitary. There were no distinctive features to differentiate IFPs from other mural or intraluminal lesions of the gastrointestinal tract.

Suture granuloma of the stomach following splenectomy.

An unusual case of a suture granuloma developing four years after splenectomy and stimulating an intramural gastric neoplasm is presented. Radiologist should be aware of this entity and include it in their differential diagnosis of intramural gastric masses in postoperative patients.

Gastric polyps in familial polyposis coli.

Familial polyposis coli has been considered a disease in which polyps are confined to the colon and rectum. The authors recently saw 3 cases in which either adenomatous or hyperplastic polyps were also present in the stomach and duodenum. The polyps were detected only by endoscopy or air-contrast radiographic examination. These cases and other recent studies indicate that gastric and duodenal polyps are more common in familial polyposis coli than previously recognized and should be considered an integral part of the syndrome.

Radiologic features of multinodular lymphoma of the colon.

The colon is frequently involved in patients with systemic malignant lymphoma and may be the site of initial clinical presentation. Multiple nodules are one of the manifestations of colonic lymphoma. In an effort to determine the most useful and characteristic features, the radiographic findings in 23 patients with multinodular colonic lymphoma were reviewed. The most characteristic radiographic features were identified: (1) variably sized, smooth, sessile nodules with an average diameter of 7 mm; (2) a cecal mass larger than 3 cm; (3) distortion of the haustra ; (4) incomplete evacuation of barium; and (5) involvement of the stomach, small bowel, or spleen. Less common were irregular, pedunculated, or filiform nodules and occasional umbilication . The differential diagnosis includes gastrointestinal polyposis, benign lymphoid hyperplasia, and inflammatory bowel disease. The radiologist may be the first to suggest the correct diagnosis when lymphoma patients present with multiple colonic nodules.