Enterography CT without and with water enema in patients with Crohn's disease: Results from a comparative observational study in comparison with endoscopy.

OBJECTIVES: CT is nowadays an examination routinely performed in Crohn's disease (CD) patients. However, there are several ways to assess gastro-intestinal tract, in particular colonic segments. Aim of this study is to compare enterography-CT (E-CT), performed after oral administration of polyethylene-glycol solution (PEG-CT) versus enterography-CT performed also with water enema via rectum (ECT-WE) in patients with CD. METHODS: We have studied 79 patients with CD undergone to enterography-CT (42 evaluated with PEG-CT and 37 with ECT-WE) who have performed a lower endoscopy within 15 days before CT. CT results concerning large bowel were compared with endoscopic findings. Intestinal distension, discomfort of the patients, sensitivity, specificity and diagnostic accuracy were evaluated. Pearson test was used for statistical analysis. RESULTS: Degree of abdominal pain was significantly higher in patients underwent to ECT-WE compared to PEG-CT. Distension of the colon was significantly greater in patients studied with ECT-WE compared to those studied with PEG-CT. Values of sensitivity, specificity and diagnostic accuracy of PEG-CT and ECT-WE were respectively 77, 86.5 and 81%, and 89, 100 and 92% in comparison with endoscopy. CONCLUSIONS: In patients with CD, ECT-WE allows the evaluation of large bowel in addition to small bowel better than PEG-CT.

Comparison between clinical and radiological evaluation before and after medical therapy in patients with Crohn's disease: new prospective roles of CT enterography.

PURPOSE: In recent years, CT enterography (CTE) has emerged as an important methodology to study patients with Crohn's disease (CD). The aim of this study was to evaluate the correlation between clinical response to therapy and CTE findings in CD patients. MATERIALS AND METHODS: Forty-five patients with proven CD underwent CTE before and after medical therapy. In CTE we evaluated bowel thickness, longitudinal extension of parietal thickening, presence of target signs and extraintestinal signs. The clinical response to therapy was judged based on clinical global assessment and classified as improved, worsened or stable disease. Radiological judgement was compared to clinical judgement. The Cohen kappa test, t test or Anova analysis and χ (2) test were used for comparisons. RESULTS: Among 45 enrolled patients, 21 (47 %) improved clinically, five (11 %) worsened, 19 (42 %) remained stable. Clinical improvement was significantly correlated to reduced intestinal thickness, reduced longitudinal extension of the disease, increased diameter of pathological bowel and reduced target signs (p < 0.05). Worsening conditions were significantly correlated to increased longitudinal extent, increased parietal thickness and reduced lumen diameter (p < 0.05). CT judgement was in agreement with physician's clinical assessment in 34 patients (76 %), showing improved disease in 16/21 patients (76 %), stable disease in 14/19 patients (74 %) and worsening in 4/5 patients (80 %). No agreement was observed in 11 (24 %) patients. CONCLUSIONS: CT enterography provide specific and measurable parameters in evaluating the response to therapy in CD patients.

Enteroclysis CT and PEG-CT in patients with previous small-bowel surgical resection for Crohn's disease: CT findings and correlation with endoscopy.

The aim of this study was to evaluate the accuracy of multidetector CT in patients with Crohn's disease (CD) relapse after ileocolic resection compared with endoscopy. Thirty-four patients were studied by endoscopy and multidetector CT, after oral administration of polyethylene glycol solution (n = 21) or after administration of methylcellulose via nasojejunal tube (n = 13). In CT examinations we evaluated the presence of mural thickening, target sign, perienteric stranding, comb sign, fibrofatty proliferation and complications. Endoscopic results were classified in accordance with Rutgeerts score (from 0 to 4). The statistical evaluations were carried out by using Fisher's exact text and chi (2) testing (p < 0.05, statistically significant difference). Sensitivity, specificity and accuracy of the CT were 96.9%, 100% and 97%, respectively. We found a statistically significant correlation between an endoscopic score of 4 and the CT signs of target sign, perienteric stranding, comb sign and fibrofatty proliferation, and between scores 1 and 2 and mucosal hyperdensity without or with mural thickening, respectively (p < 0.05). Moreover, only CT identified the presence of jejunal and proximal ileum disease in two and three patients, respectively, and fistulas in three patients. CT is a reliable method in the diagnosis of CD relapse and shows agreement with the approved endoscopic Rutgeerts score.

Small-bowel neoplasms: prospective evaluation of MR enteroclysis.

PURPOSE: To prospectively evaluate the accuracy of magnetic resonance (MR) enteroclysis in the detection of small-bowel neoplasms in symptomatic patients, with conventional endoscopy, tissue specimen, capsule endoscopy, conventional enteroclysis, and follow-up findings as reference standards. MATERIALS AND METHODS: The study protocol was approved by the human research committee, and all patients gave written informed consent. One hundred fifty patients (83 male, 67 female; mean age, 42.6 years; age range, 17-84 years) who were clinically suspected of having small-bowel neoplasm and whose previous upper and lower gastrointestinal endoscopy findings were normal underwent MR enteroclysis. The MR enteroclysis findings were prospectively evaluated for the presence of focal bowel wall thickening, small-bowel masses, and small-bowel stenosis. Positive MR enteroclysis findings were compared with histopathologic examination results obtained after surgical (n = 19) or endoscopic (n = 2) procedures. Negative MR enteroclysis results were compared with the results of enteroscopy (n = 5), capsule endoscopy (n = 53), or conventional enteroclysis with subsequent clinical follow-up (n = 71). The diagnostic performance of MR enteroclysis was analyzed on a per-patient basis. RESULTS: MR enteroclysis was successfully completed in all 150 patients and enabled correct detection of 19 small-bowel neoplasms, which were confirmed at histopathologic examination: three carcinoid neoplasms, two adenocarcinomas, two stromal tumors, five lymphomas, one angiomatous mass, three small-bowel metastases, one leiomyoma, one adenoma, and one lipoma. Overall sensitivity, specificity, and accuracy in identifying patients with small-bowel lesions were 86% (19 of 22), 98% (126 of 128), and 97% (145 of 150), respectively. Two MR enteroclysis examinations yielded false-positive findings, and three yielded false-negative findings. CONCLUSION: MR enteroclysis is an accurate modality for detecting small-bowel neoplasms in symptomatic patients.

CT findings and clinical activity in Crohn's disease.

The aim of this study was to evaluate clinical correlations of CT signs in proven Crohn's disease. Fifty patients were studied by means of multidetector CT. Clinical activity was assessed using Crohn's disease activity index (CDAI) score and some laboratory parameters. All patients with CDAI>150 had CT study scored as pathological. Seventy-nine percent of patients with CDAI<150 showed abnormalities in CT exam. CT findings correlate with some parameters of disease activity, thus underlining the usefulness of performing CT enteroclysis in Crohn's disease patients.

MR imaging and MR cholangiopancreatography in the preoperative evaluation of hilar cholangiocarcinoma: correlation with surgical and pathologic findings.

The primary aim was to evaluate delayed contrast-enhanced MRI in depicting perineural spread of hilar cholangiocarcinoma (CCC) and consequently to determine the capability of MRI/MRCP for staging CCC. Fifteen patients that underwent MRI/MRCP and surgical treatment were retrospectively included. Two radiologists evaluated MR images to assess delayed periductal enhancement, extent of bile duct stenosis, liver parenchymal and vascular involvement and presence of liver atrophy. An agreement between delayed enhancement of the bile duct walls and perineural neoplastic spread showed a very good correlation factor (0.93). The overall accuracy in detecting biliary neoplastic invasion was higher for delayed T1-weighted images (93.3%) than for the MRCP images (80%), and T1-delayed image increased the MR accuracy in assessing the neoplastic resectability (p<0.05). MRI correctly predicted vascular involvement in 73% and liver involvement in 80% of the cases. The number of overall correctly assessed patients with regard to resectability was 11 true positive, 1 false positive and 3 true negative. The combination of MRI/MRCP is a reliable diagnostic method for staging hilar cholangiocarcinomas. Delayed periductal enhancement is accurate in the evaluation of neoplastic perineural spread, and it can improve diagnostic accuracy to identify resectable and unresectable tumours.

Multidetector CT enteroclysis versus barium enteroclysis with methylcellulose in patients with suspected small bowel disease.

The purpose of this study was to evaluate the diagnostic accuracy of multidetector-CT enteroclysis (MDCT-E) versus barium enteroclysis with methylcellulose (BE) in clinically selected patients with suspected small bowel disease. We prospectively studied 52 patients who underwent unenhanced and contrast-enhanced multidetector CT (16 rows) after administration of 2-2.5 l of methylcellulose by naso-jejunal tube. BE was performed after administration of barium 60% w/v (200-250 ml) and methylcellulose (1-2 l). Patients with radiological signs of Crohn's disease were classified into the following subtypes: active, fibrostenotic, fistulising/perforating, reparative or regenerative subtypes. Twenty-eight patients also underwent endoscopy. The radiological prevalent subtype was the active subtype. The sensitivity, specificity and diagnostic accuracy of MDCT-E versus BE was 83%, 100% and 89%, respectively. BE showed five false negative CT cases due to early Crohn's disease; endoscopy confirmed positive cases of the CT and the BE, but showed one false negative case of the BE. Together, MDCT enteroclysis and BE permitted the diagnosis of Crohn's disease in 30 patients, adhesions in one patient, lymphoma in two patients and carcinoid tumours in two patients. In conclusion, MDCT-E permits good representation of pathological patterns. Early stages of Crohn's disease are better evaluated by BE.

Pneumomediastinum and abdominal pain: which correlation?

The case of a female patient with abdominal pain, fever and dyspnea appeared abruptly, is reported. Two days previously the patient underwent endoscopic colic polypectomy. Preliminary abdominal and chest X-ray showed colic and tenual air-fluid levels, a modest amount of pneumomediastinum and soft tissue emphysema of the neck. The cause of the latter finding was referable to five sites of origin: the lung parenchyma, mediastinal airways, the esophagus, the neck and the abdominal cavity. For symptom worsening thoracoabdominal CT was performed. It confirmed the pneumomediastinum and soft tissue emphysema of the neck and presence of intra and retroperitoneal free air as for perforation. Colonoscopy is a routine procedure in the diagnosis and therapy of colonopathies, but colic iatrogenic perforation is a dangerous complication not to be underestimated.

Reasoned diagnostic approach to a case of small bowel obstruction.

The case of a 73-year-old male patient come to the Emergency Department for epigastric pain, vomiting and blocked bowel movement is presented. Plain abdominal X-ray performed on emergency showed marked small bowel distention, and air-fluid levels suggestive of intestinal obstruction. CT was indicated to establish its precise site and cause. The presence of a gallstone was evidenced: gallstone ileus was diagnosed. Interestingly enough, at surgery the gallstone was not found; most likely it was expelled spontaneuously during the time elapsed between CT and surgery. Based on imaging findings and a review of the literature it was concluded that the study patient had a rare association of intestinal volvulus and gallstone ileus.

Magnetic resonance imaging of cholangiocarcinoma.

Cholangiocarcinoma arises from the bile ducts and is the most common primary malignancy of the biliary tree. Cholangiocarcinoma is classified according to its growth pattern: mass-forming, periductal-infiltrating, or intraductal-growing type. The majority of cholangiocarcinomas occur at the common hepatic duct (CHD) and its bifurcation, also referred to as Klatskin's tumor, but they also can occur in more peripheral branches within the hepatic parenchyma. Microscopically, cholangiocarcinoma represents an adenocarcinoma with a glandular appearance arising from the epithelium of the bile ducts. On magnetic resonance (MR) images, cholangiocarcinomas appear hypointense on T1-weighted images, and hyperintense on T2-weighted images. Central hypointensity can be seen on T2-weighted images and correspond to fibrosis. On dynamic MR images, cholangiocarcinomas show moderate peripheral enhancement followed by progressive and concentric filling in the tumor with contrast material. Pooling of contrast within the tumor on delayed MR images is suggestive of peripheral cholangiocarcinoma. The role of MR imaging in hilar cholangiocarcinoma is to confirm/reach a diagnosis and to assess resectability. Hilar cholangiocarcinoma shows the same signal intensity pattern of peripheral tumors both on T1- and T2-weighted images. On magnetic resonance cholangiopancreatography (MRCP) images, hilar cholangiocarcinoma appears as a moderately irregular thickening of the bile duct wall (>/=5 mm) with symmetric upstream dilation of the intrahepatic bile ducts. The aim of preoperative investigation in Klatskin tumors typically requires the evaluation of the level of biliary obstruction, the intrahepatic tumor spread, and the vascular involvement; it also needs to show any atrophy-hypertrophy complex. Because of its intrinsic high tissue contrast and multiplanar capability, MR imaging and MRCP are able to detect and preoperatively assess patients with cholangiocarcinoma, investigating all involved structures such as bile ducts, vessels and hepatic parenchyma. The main reason for surgical/imaging discrepancy is represented by the microscopic diffusion along the mucosa and in the perineural space.

IHE: integrating the healthcare enterprise, towards complete integration of healthcare information systems.

Information systems of a modern hospital govern extremely important functions as patient management, control of work flows, administration etc. However a great variety of recommended standards are used while in most cases no effective coordination and intercommunication is possible. Some years ago to simplify and resolve this problem IHE was created; it is a technical framework which identifies a number of components of the healthcare enterprise (the "actors") whose interactions are defined in terms of "transactions", that should be implemented according to HL7 and DICOM standards. Attempting an in-depth understanding of IHE structure and its principles of function, those transactions that can occur among the various actors, which of these are supported and which require specific actors, are analyzed. IHE is continuously evolving, therefore open to the factual contribution of all health professionals who can point out the main instances that emerge daily from their activity in the field. While its origin was specific for the field of radiology, the true soul and driving force of the project lay on the type of approach used: to get together medical specialists and information technology professionals in order to identify and solve the difficulties which hindered an effective and functional integration of healthcare information systems.

Combined diagnostic imaging of intestinal involvement in Henoch-Schönlein purpura.

The case of a 39-year-old male patient with symptoms of persistent abdominal pain and melena, affected by Henoch-Schönlein purpura, is reported. Abdominal CT was requested. The examination was justified by the fact that symptoms could be correlated with other pathological conditions (volvulus, neoplasms, Chron's disease, etc.) which had to be excluded. For optimum study of the abdominal wall, correct preparation and the use of oral contrast agents were required. From the analysis of CT findings, in particular loop thickening with stratified density, the increased density of mesenteric fat and the presence of fluid among loops led to the radiological diagnosis of intestinal involvement in Henoch-Schönlein purpura. Other imaging procedures (double contrast enema, sonography, Doppler US, MRI) now used in the study of intestinal loops, are examined.

Diagnostic imaging of esophageal web.

The case of a 79-year-old female patient with chest pain, palpitations and dysphagia is presented. The patient was sent to the Diagnostic Imaging department for barium study of the upper digestive tract. From the analysis of findings of fast digital imaging the various disorders and diseases that could be responsible for them, were considered. All alternative situations (pharyngeal venous plexus, cricopharyngeal muscle, vertebral osteophytosis, thyroid struma etc) were excluded and the diagnostic suspicion led to the diagnosis of esophageal web (thin mucous membrane within the lumen). For diagnostic completion esophagoscopy was performed. It confirmed the diagnostic suspicion and allowed treatment by dilatation that resulted in a marked benefit to the patient.

Intestinal lymphangiectasia.

The case of a 26-year-old female patient with abdominal pain, nausea, hypoproteinemia, enteric loss of plasma proteins, lymphedema, severe steatorrhea and malabsorption, is presented. Enteroclysis and sonography were performed. Based on the case history and the characteristics of focal lesion and intestinal folds provided by the two radiologic examinations, a specific diagnosis of intestinal lymphangiectasia, confirmed at biopsy, could be established. Intestinal lymphagiectasia is a very uncommon condition characterized by dilated submucosal lymphatic channels.

Diagnostic imaging of the small bowel in a case of occult gastrointestinal bleeding.

A case of a male patient with occult gastrointestinal bleeding and negative gastroscopy and colonoscopy is presented and discussed. Oral small bowel barium follow-through was performed upon the patient request. It documented a jejunal neoformation. The analysis of radiologic findings directed towards a probably extramucosal origin. Subsequent CT evaluation confirmed a neoformation inseparable from a jejunal loop with inhomogeneous contrast enhancement, therefore of suspected malignant nature. The histological examination on the surgical specimen documented the presence of a stromal tumor of indeterminate malignancy.

A prospective trial comparing small bowel radiographs and video capsule endoscopy for suspected small bowel disease.

BACKGROUND & AIMS: This study was undertaken to prospectively compare the clinical outcomes of small bowel radiographs with the wireless capsule endoscopy. METHODS: Twenty-two patients were selected consecutively because of suspected small bowel disease. Two patients were excluded owing to ileal stenosis. Thus, the results of barium follow-through and the Given M2A wireless video capsule (Given Imaging Ltd., Yoqneam, Israel) endoscopy were compared in 20 patients (13 men; mean age, 52.5 yr; range, 29-78 yr). RESULTS: Barium follow-through was normal in 17 patients and showed ileal nodularity in 3 patients. Capsule endoscopy was normal in 3 patients and showed positive findings in the remaining 17 patients. The barium study was considered diagnostic in 4 (20%) patients. The capsule endoscopy was considered diagnostic in 9 (45%) patients, suspicious in 8 (40%) patients, and failed in 3 (15%) patients. For obscure gastrointestinal (GI) bleeding, the diagnostic potential of barium follow-through was much worse as compared with the capsule endoscopy (5% vs. 31%, P < 0.05). Capsule endoscopy was well tolerated and better accepted by patients when compared with the most recently performed endoscopic procedure. CONCLUSIONS: The video capsule endoscope was found to be superior to small bowel radiograph for evaluation of small bowel diseases. However, this novel wireless endoscope system needs further assessment because of limitations such as difficulties in interpretation of potentially nonspecific findings.

Idiopathic chronic pancreatitis in children: MR cholangiopancreatography after secretin administration.

PURPOSE: To assess the accuracy of dynamic magnetic resonance (MR) cholangiopancreatography after secretin administration in detecting pancreatic duct abnormalities typical of early-onset idiopathic chronic pancreatitis in children with recurrent episodes of idiopathic acute pancreatitis. MATERIALS AND METHODS: Fifteen children (mean age, 11.3 years; range, 6-17 years) with at least three recurrent episodes of idiopathic acute pancreatitis prospectively underwent MR cholangiopancreatography before and after secretin administration. Image analysis included visualization of side branches, ductal narrowing, endoluminal filling defects, irregular ductal contour, cavities, and pancreas divisum. All patients underwent endoscopic retrograde cholangiopancreatography (ERCP). RESULTS: Dilated side branches were detected in three (20%) of 15 patients on MR cholangiopancreatograms obtained before secretin administration and in seven (47%) of 15 patients on images obtained after secretin administration. Ductal narrowing was detected in one (7%) of 15 patients on images obtained before secretin administration and in two (13%) of 15 patients on images obtained after secretin administration. Endoluminal filling defects in one (7%) of 15 patients were observed on MR cholangiopancreatograms obtained both before and after secretin administration. Irregular contour of the main pancreatic duct was present in four (27%) of 15 patients on MR cholangiopancreatograms obtained before secretin administration and in five (33%) of 15 patients on images obtained after secretin administration. Cavities and pancreas divisum were detected in one (7%) of 15 patients and in two (13%) of 15 patients, respectively, only on MR cholangiopancreatograms obtained after secretin administration. CONCLUSION: Secretin improves the sensitivity of MR cholangiopancreatography in diagnosing early-onset idiopathic chronic pancreatitis.

Combined diagnostic imaging of Crohn's disease: an outlook.

Crohn's disease is an inflammatory disease of the mucosa and bowel wall layers involving peritoneal, mesenteric structures and lymph nodes. The combination of the various imaging procedures plays a major role in the evaluation of Crohn's disease patients, based on which an optimal definition of the disease stage is achieved. This is required for a correct therapeutic strategy that can be exclusively medical, surgical or elective in complications. In the combined approach, the follow-through study of the small bowel and enteroclysis in particular, represents the examination of choice to document the early disease, early signs of recurrence with the demonstration of all mucosal alterations, including fistulous tracts. Sonography, CT and MRI allow the evaluation of Crohn's location in the wall and adjacent region. Preliminary results of CT-enteroclysis and MR-enteroclysis seem able to document mucosal alterations and morphofunctional characteristics In the near future these new examinations could become a real one-stop-shop coupled with wireless endoscopy in the study of Crohn's disease.

The state of the art of small bowel imaging: combine the old with the new.

Barium contrast examinations are the reference methods for the detection of morphological intraluminal alterations of the small bowel. Oral small bowel examination in many Centers has been replaced by small bowel enteroclysis. It allows optimal filling of intestinal loops, through a nasojejunal tube and the diagnostic sensitivity and specificity are higher as compared to the conventional examination. US, CT and MRI are useful diagnostic procedures in the evaluation of parietal and extraparietal alterations and in the study of complications of small bowel disease. In recent years, CT-enteroclysis and MR-enteroclysis have been developed, both enable the evaluation of luminal, extraluminal and mural alterations of the small bowel. Diagnostic imaging plays a major role in the study of the small bowel. The most appropriate diagnostic method should be selected, based on the clinical observations and on the availability of the technique.