Prognostic value of diffusion-weighted magnetic resonance imaging of brain in fetal growth restriction: results of prospective multicenter study.

OBJECTIVE: To measure prospectively apparent diffusion coefficient (ADC) values between 28 and 32 weeks of gestation in different cerebral territories of fetuses with estimated fetal weight (EFW) ≤ 5th centile, and analyze their association with adverse perinatal outcome. METHODS: This was a prospective study involving six tertiary-level perinatal centers. In the period 22 November 2016 to 11 September 2017, we included singleton, small-for-gestational-age (SGA) fetuses with EFW ≤ 5th percentile, between 28 and 32 weeks of gestation, regardless of the umbilical artery Doppler and maternal uterine artery Doppler findings. A fetal magnetic resonance imaging (MRI) examination with diffusion-weighted sequences (DWI) was performed within 14 days following inclusion and before 32 weeks. ADC values were calculated in the frontal and occipital white matter, basal ganglia and cerebellar hemispheres. An ultrasound examination was performed within 1 week prior to the MRI examination. The primary outcome was a composite measure of adverse perinatal outcome, defined as any of the following: perinatal death; admission to neonatal intensive care unit with mechanical ventilation > 48 h; necrotizing enterocolitis; Grade III-IV intraventricular hemorrhage; periventricular leukomalacia. A univariate comparison of median ADC values in all cerebral territories between fetuses with and those without adverse perinatal outcome was performed. The association between ADC values and adverse perinatal outcome was then analyzed using multilevel logistic regression models to adjust for other common prognostic factors for growth-restricted fetuses. RESULTS: MRI was performed in 64 patients, of whom five were excluded owing to fetal movement artifacts on DWI and two were excluded for termination of pregnancy with no link to fetal growth restriction (FGR). One intrauterine death occurred secondary to severe FGR. Among the 56 liveborn neonates, delivered at a mean ± SD gestational age of 33.6 ± 3.0 weeks, with a mean birth weight of 1441 ± 566 g, four neonatal deaths occurred. In addition, two neonates required prolonged mechanical ventilation, one of whom also developed necrotizing enterocolitis. Overall, therefore, seven out of 57 (12.3%) cases had an adverse perinatal outcome (95% CI, 3.8-20.8%). The ADC values in the frontal region were significantly lower in the group with adverse perinatal outcome vs those in the group with favorable outcome (mean values of both hemispheres, 1.68 vs 1.78 × 10-3 mm2 /s; P = 0.04). No significant difference in ADC values was observed between the two groups in any other cerebral territory. A cut-off value of 1.70 × 10-3 mm2 /s was associated with a sensitivity of 57% (95% CI, 18-90%), a specificity of 78% (95% CI, 63-88%), a positive predictive value of 27% (95% CI, 8-55%) and a negative predictive value of 93% (95% CI, 80-98%) for the prediction of adverse perinatal outcome. A mean frontal ADC value < 1.70 × 10-3 mm2 /s was not associated significantly with an increased risk of adverse perinatal outcome, either in the univariate analysis (P = 0.07), or when adjusting for gestational age at MRI and fetal sex (odds ratio (OR), 6.06 (95% CI, 0.9-37.1), P = 0.051) or for umbilical artery Doppler (OR, 6.08 (95% CI, 0.89-41.44)). CONCLUSION: This first prospective, multicenter, cohort study using DWI in the setting of SGA found lower ADC values in the frontal white-matter territory in fetuses with, compared with those without, adverse perinatal outcome. To determine the prognostic value of these changes, further standardized evaluation of the neurodevelopment of children born with growth restriction is required. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Sphincter of Oddi dysfunction and unexplained abdominal pain: clinical and manometric study.

Unexplained, biliary-type abdominal pain is often attributed to an abnormal pressure profile of the sphincter of Oddi. In spite of this assumption, the true prevalence of this type of motor dysfunction among cholecystectomized patients with unexplained abdominal pain is not known. We studied 64 postcholecystectomy patients who were thought to have sphincter of Oddi dysfunction. Radiologically, other than a dilated common bile duct in some, they had no anatomic derangement of their pancreatobiliary tract to explain their symptoms. They were categorized into three groups on the basis of four objective findings suggesting abnormal biliary emptying mechanism. Basal sphincter of Oddi pressure, frequency of phasic contractions, and proportion of retrograde contractions were determined in all patients. Twenty-six (41%) of the patients demonstrated at least one motor abnormality, 16 (25%) had two, and 10 (16%) had all three abnormal parameters. The pressure profile of the sphincter was normal in 38 or 59% of the patients. Seventy-three percent (73%) of the patients in group I, who had three or four of the objective findings for sphincter of Oddi dysfunction, demonstrated at least one motor abnormality. Sixty percent of this group demonstrated an increased basal sphincter of Oddi pressure. On the other hand, only 19% of the patients in group III, who had none of the objective findings, revealed a motor abnormality. Increased basal sphincter of Oddi pressure was noted in 7% of this group. We conclude that, sphincter of Oddi dysfunction, as diagnosed manometrically, explains the recurrent biliary type abdominal pain in a minority of patients.(ABSTRACT TRUNCATED AT 250 WORDS)

The role of the flow rate of the pneumohydraulic system on post-sphincter of Oddi manometry pancreatitis.

Manometry of sphincter of Oddi (SO) carries a risk of acute pancreatitis by a mechanism not yet clearly understood. This study attempted to evaluate the role of the flow rate of the perfusion system in the development of acute pancreatitis. During the past 60 months, we have performed 81 manometry studies of SO in 79 patients, 61 women and 18 men, who were referred for recurrent attacks of abdominal pain suggestive of SO dysfunction. All procedures were done by the same operator, utilizing the same instrumentation and similar premedication. In the first 54 studies, the pneumohydraulic system had a flow rate of 0.55 ml/min and a tank pressure of 15 lb/in2 while in the last 27 studies a flow rate of 0.27 ml/min and a pressure of 7.5 lb/in2 were employed. Acute pancreatitis was diagnosed after 16 (19.7%) procedures. Fourteen (26%) of them occurred after high-flow-rate perfusion. In contrast, only 2 (7%) of the 27 patients who had the procedure done at the flow rate developed this complication (p less than 0.05). There was no correlation between the occurrence of pancreatitis, clinical suspicion of SO dysfunction, and the underlying manometric profile of the sphincter. We conclude that the incidence of procedure-related pancreatitis after manometry of SO is higher than following diagnostic endoscopic retrograde cholangiopancreatography and that the flow rate in the perfusion system is a precipitating factor in the development of this complication.

Bile duct dyskinesia. Clinical and manometric study.

Unexplained right upper quadrant symptoms have often been attributed to bile duct dyskinesia. In this study we evaluated the pressure profile of the sphincter of Oddi in 10 patients with recurrent episodes of right upper quadrant pain, intermittent mild transaminasemia, and a normal pancreatobiliary tract. Nine healthy volunteers served as control. A triple-lumen catheter with an external diameter of 1.7 mm and recording sites at 2-mm intervals was introduced into the papilla through the endoscope. Ductal pressure, basal sphincter of Oddi pressure, and the amplitude and propagation direction of the phasic contractions of the sphincter were determined in patients and subjects. All measurements were performed relative to duodenal pressure, which was taken as zero. There was no significant difference between patients and subjects in the amplitude and frequency of phasic contractions of sphincter of Oddi. In contrast, the patients demonstrated a higher sphincter of Oddi pressure (p less than 0.005) and increased proportion of retrograde propagation direction of phasic contractions (p less than 0.01). It is concluded that a subpopulation of patients with unexplained abdominal pain demonstrated abnormal pressure profile of the sphincter of Oddi.